Maternal and Newborn Standards and Indicators Compendium 2004 2

Maternal and Newborn
Standards and
Indicators Compendium
Maternal and Newborn
Standards and Indicators
Compendium
December 2004
The CORE Group, a membership association of international nongovernmental organizations
(NGOs) registered in the United States, promotes and improves the health and well being of women
and children in developing countries through collaborative NGO action and learning. Collectively,
its member organizations work in more than 140 countries, supporting health and development
programs. CORE’s Safe Motherhood and Reproductive Health Working Group supports NGOs
to engage communities for better sexual and reproductive health for all by sharing knowledge
resources and promoting the most up-to-date evidence-based practices, including those affecting safe
delivery and newborn health.
The U.S. Agency for International Development (USAID) is committed to improving the health
and well being of women and their families in the developing world. For more than 40 years, USAID
has worked in partnership with private voluntary organizations, American businesses, international
agencies, indigenous organizations, universities, other governments, and other U.S. government agen-
cies to implement quality development programs and projects. USAID improves the health and quality
of life of millions of women and children worldwide through its investments in quality maternal and
neonatal health programs.
This publication was made possible by support from
the Bureau for Global Health, United States Agency for
International Development (USAID) under coopera-
tive agreement FAO-A-00-98-00030. This publication
does not necessarily represent the views or opinion of
USAID.
Recommended Citation
Safe Motherhood and Reproductive Health Working Group, CORE Group, Maternal and Newborn
Standards and Indicators Compendium, Washington, D.C: December 2004.
Abstract
The Maternal and Newborn Standards and Indicators Compendium is designed to assist program
designers in selecting essential components, actions and appropriate indicators for chosen interven-
tions in maternal and newborn care. It includes five interrelated tables that correspond to the temporal
phases of a woman’s reproductive cycle: 1) Pre-Conception/ Inter-Conception; 2) Antenatal; 3) Labor
and Delivery; 4) Postpartum Care; and 5) Newborn Care. The Compendium provides NGOs with
a single source of information to: 1) determine recommended practices and standards of care at the
household, community, and health care facility levels to address maternal and newborn care, and
2) identify which indicators are appropriate to use with the different interventions. Endnotes with
detailed technical information and essential references are included.
Cover photo credits: Virginia Lamprecht/USAID (Albania, Guatemala) and Valenda Campbell/CARE
(Malawi, Sierra Leone).
Design by: Kathy Strauss, ImageWerks lc.
CORE Group
300 I Street, NE
Washington D.C 20002
www.coregroup.org
Table of Contents
Page v Acknowledgements
vii Acronyms
1 Introduction
2 What Is the Compendium?
2 What Is the Purpose of the Compendium?
3 How Can the Compendium of Standards and Indicators Be Used?
4 Future Editions of this Compendium
5 Intervention Focus: Pre-Conception/Inter-Conception Care [PC]
21 Intervention Focus: Antenatal Care [AC]
35 Intervention Focus: Labor and Delivery [LD]
47 Intervention Focus: Postpartum Care [PP]
61 Intervention Focus: Newborn Care [NC]
73 Appendix 1: Key Indicators
77 Appendix 2: Programming for Maternal and Newborn Health
Figures
78 Figure 1: Generic Results Framework
80 Figure 2: Illustrative Program Design for Prevention of Maternal
Mortality at the Community and Facility Levels
85 Figure 3: Timing of Maternal and Newborn Care Interventions
85 Figure 4: Evidence-based Interventions for Major Causes of
Maternal Mortality
86 Figure 5: Evidence-based Interventions for Major Causes of
Neonatal Mortality
88 Figure 6: Integration of Essential Maternal and Newborn Care
and PMTCT
Tables
79 Table 1: Selecting Interventions by Desired Outcomes (Objective)
81 Table 2: CARE's Programming Approach
82 Table 3: Needs Assessment for Maternal and Newborn Health
84 Table 4: Maternal Conditions and Potential Maternal and
Perinatal Outcomes
Table of Contents iii

Acknowledgements
Virginia Lamprecht, in her role as Chair of the CORE Safe Motherhood and Reproductive
Health (SMRH) Working Group, led the development of the Maternal and Newborn
Standards and Indicators Compendium over a two-year period, and continued to provide
technical advice and support in her role as Technical Advisor in the Office of Population
and Reproductive Health at the U.S. Agency for International Development (USAID). Her
dedication and attention to detail has ensured the high quality of this product.
Sandra Tebben Buffington and Annie Clark of the American College of Nurse Midwives
(ACNM) provided their expertise in drafting the initial set of standards and indicator tables
and detailed endnotes, and then participated in several rounds of discussion and reviews to
ensure that this product represented the best known guidance available at this time. This
product would not have been possible without their collaboration and diligence.
CORE’s SMRH Working Group extends sincere gratitude to the many experts who shared
their time and talent in creating and reviewing these programming standards and indicators.
These include:
Erin Anastasi, ADRA Debbie Herold, ADRA

Frank Anderson, University of Michigan Jenna Houston, Midwives for Midwives
Debbie Armbruster, ACNM Susan Igras, CARE
Sharon Arscott-Mills, USAID Lily Kak, USAID
Annette Bongiovanni, AED Barbara Kinzie, JHPIEGO
Lisa Bowen, Plan Marge Koblinsky, JHU
Jean Capps, Independent Mary Kroeger, Independent
Rebecca Casanova, Family Care Int. Karen LeBan, CORE
Annie Clark, ACNM Judiann McNulty, Mercy Corps
Ann Davenport, Independent Gloria Metcalfe, JHPIEGO
Emmanuel D’Harcourt, IRC Allison Moran, JHPIEGO
Erin Eckert, ORC/MACRO Winifride Mwebesa, Save the Children
Catherine Elkins, JHPIEGO Susan Otchere, Save the Children
Sushie Englebrecht, PRIME Michel Pacque, ORC/MACRO
Donna Espeut, ORC/MACRO Mary Beth Powers, Save the Children
Rebecca Casanova, FCI Judith Robb-McCord, JHPIEGO
Veronica Dupont, CATALYST Alfonso Rosales, CRS
Joy Fishel, JHPIEGO Mandy Rose, BASICS II
Frances Ganges, Save the Children Julia Ross, CORE
Patricia Gomez, JHPIEGO Susan Rae Ross, Independent
Melissa Gossett, CORE Leo Ryan, ORC/MACRO
Steve Harvey, URC La Rue Seims, Save the Children
Acknowledgements v
Theresa Shaver, White Ribbon Alliance Patricia Stephenson, USAID
Lynn Sibley, Emory University Sharon Tobing, Independent
Sara Smith, CORE Donna Vivio, JHPIEGO
Cindy Stanton, JHU Susan Youll, USAID
Mary Ellen Stanton, USAID Jennifer Yourkavitch, Independent
Ann Starrs, Family Care International Laurie Zivetz, Independent
Although many people participated in task forces over the three years of this effort, sev-
eral people deserve special recognition. Debbie Herold, Karen LeBan, Michel Pacque,
Teresa Shaver and Jennifer Yourkavitch oversaw the final version of the compendium. The
CATALYST Consortium provided financial support for hosting a technical review meet-
ing held at ORC/Macro headquarters in December 2003. Leo Ryan, Director of the Child
Survival Technical Support (CSTS+) Project at ORC/Macro, facilitated the event.
The CORE SMRH Working Group presents this document as a reference guide for the
nongovernmental organization (NGO) community, understanding that as the evidence base
changes so will this guidance. This guide presents the most up-to-date information at the
time it was written. Users of this Compendium may keep abreast of new developments in
standards of care and recommended practices by checking with experts in the field and by
consulting the web-based resources listed at the end of the Compendium.
This collection of programming standards and indicators is dedicated to the 1,440 women
around the world who die in pregnancy or childbirth each day, and to the thousands of
women who suffer disability due to labor.
December 2004
vi Maternal and Newborn Standards and Indicators Compendium

Acronyms
ACNM American College of Nurse-Midwives

ADRA Adventist Development and Relief Agency International
AED Academy for Educational Development
AIDS acquired immune deficiency syndrome
ANC antenatal care [household level: ACHH; community level: ACCL;
first level: ACFL; second level: ACSL]
ART anti-retroviral
BASICS Basic Support for Institutionalizing Child Survival project
BCC behavior change communications
BCG bacillus Calmette et Guerin
BF breastfeeding
BP blood pressure
CA cooperating agency
CARE Cooperative for Assistance and Relief Everywhere, Inc.
CBDA community-based distribution agent
CHW community health worker
CMV cytomegolovirus
CPR contraceptive prevalence rate
CRS Catholic Relief Services
C-section Cesarian section
CSHGP Child Survival Health Grants Program
CSTS+ Child Survival Technical Support project
DPT3 diphtheria, pertussis and tetanus vaccine (3rd dose)
EmOC emergency obstetric care
EOC essential obstetric care
EPI Expanded Program on Immunization
FCI Family Care International
FGC/FGM female genital cutting/female genital mutilation
FP family planning
GBV gender-based violence
HBV hepatitis B vaccine
HF health facility
Acronyms vii
HFA health facility assessment
hgb/hct hemoglobin/hematocrit
HIV human immunodeficiency virus
HMIS health management information system
IEC information, education and communication
IM intra-muscular
IMPAC integrated management of pregnancy and childbirth
IMR infant mortality rate
IPPF International Planned Parenthood Federation
IPT intermittent preventive treatment
IR intermediate result
IRC International Rescue Committee
ITN insecticide-treated net
IUD intrauterine device
IV intravenous
IVACG International Vitamin A Consultative Group
JHU Johns Hopkins University
KAP or KPC knowledge, attitudes and practices (or coverage) survey
LAM Lactational Amenorrhea Method
LBW low birth-weight
LD/L&D labor and delivery [household level: LDHH; community level: LDCL;
first level: LDFL; second level: LDSL]
ORC MACRO Macro International, Inc., Opinion Research Corporation
MIS management information system
MMR maternal mortality ratio
MOH Ministry of Health
MOV means of verification
NC newborn care [household level: NCHH; community level: NCCL;
first level: NCFL; second level: NCSL]
NCHS National Center for Health Statistics
NGO nongovernmental organization
OPV oral poliovirus vaccine
PAC post-abortion care
PC pre-conception (pre-conception/interconceptional care)
[household: PCHH; community level: PCCL; first level: PCFL;
second level: PCSL]
PCB polychlorinated biphenyls
PLA Participatory Learning Appraisal
PMTCT prevention of mother-to-child transmission (of HIV)
viii Maternal and Newborn Standards and Indicators Compendium

PPC postpartum care [household: PPHH; community level: PPCL;
first level: PPFL; second level: PPSL]
PPH postpartum hemorrhage
PROM premature rupture of membranes
RH reproductive health
RPR rapid plasma reagin test
SD standard deviation
SDM Standard Days Method
SMRH safe motherhood & reproductive health
SO strategic objective
STI sexually transmitted infection
TB tuberculosis
TBA traditional birth attendant
TFR total fertility rate
TRM Technical Reference Materials
UNAIDS Joint United Nations Program on HIV/AIDS
UNICEF United Nations Children’s Fund
URC University Research Co., LLC
USAID/GH United States Agency for International Development,
Global Health Bureau
VA vitamin A
VCCT voluntary confidential counseling and testing
VCT voluntary counseling and testing
WHO World Health Organization
WRA women of reproductive age
Acronyms ix
Introduction
Prepared by Virginia Lamprecht, RN, MSPH, MA

—Former Chair, Safe Motherhood/Reproductive Health (SMRH) Working Group, CORE
Group
“Women are not dying because of diseases we cannot treat. . . they are dying because
societies have yet to make the decision that their lives are worth saving.”
—Mahmoud Fathalla
T
he Maternal and Newborn Standards and Indicators Compendium is designed to
assist program designers working for international nongovernmental organizations
(NGOs) develop high quality programs focused on women and children.
The Maternal and Newborn Standards and Indicators Compendium is the result of a
three-year collaborative effort led by the Safe Motherhood/Reproductive Health (SMRH)
Working Group, CORE Group. The CORE Group is a membership organization of interna-
tional NGOs registered in the United States that promotes and improves the health and well
being of women and children and the communities in which they live, through collaborative
NGO action and learning.
CORE’s main collaborating partners in creating this Compendium include:
• The American College of Nurse-Midwives (ACNM), which promotes the health and
well being of women and infants within their families and communities through the
development and support of the profession of midwifery, as practiced by certified nurse
midwives, and certified midwives,
• The Child Survival Technical Support (CSTS+) Project team at ORC/Macro, a group
whose mission is to provide technical support to U.S.-based NGOs implementing child
health programs supported through the Child Survival and Health Grants Program
(CSHGP) of the United States Agency for International Development (USAID), and
• USAID, which provided financial support for this effort.
In addition, more than 40 experts in the fields of safe motherhood, reproductive health,
child survival, and program design, monitoring, evaluation, and implementation contrib-
uted to this effort by providing technical comments, providing illustrations, and offering
suggestions in the design of the Compendium. These contributing experts represent USAID
Cooperating Agencies (CAs), US-based international NGOs, universities, and USAID staff
members.
Introduction 1
What Is the Compendium?
The Maternal and Newborn Standards and Indicators Compendium consists of five inter-
related tables that correspond to the temporal phases of a woman’s reproductive cycle:
1. Pre-Conception/ Inter-Conception
2. Antenatal
3. Labor and Delivery
4. Postpartum Care
5. Newborn Care
Each table is divided into four levels that correspond to where (and to whom) most pro-
grammatic interventions and activities are focused:
1. Household—refers to behaviors and care provided by family members and other per-
sons living in the same household or compound.
2. Community—refers to health education, actions, and care provided by community
health workers (CHWs) and educators, community-based distribution agents (CBDAs),
traditional birth attendants (TBAs), local community leaders, community groups, tradi-
tional healers, and junior health staff (such as auxiliary nurses) at health posts.
3. First-Level Care—refers to basic or Essential Obstetric Care (EOC) provided by phy-
sicians and/or midwives, nurses, paramedical, and support staff at a health center.
Essential Obstetric Care represents the minimum amount of interventions needed to
promote a healthy pregnancy and birth outcome. This includes antenatal care (screen-
ing for infection, diseases, provision of tetanus toxoid injections, good nutrition), birth
planning, ensuring delivery with a skilled attendant, proper referral for the management
of obstetrical complications (emergency obstetric care), and post-partum monitoring
and care.
4. Second-Level Care—refers to comprehensive [emergency] obstetric care (including
blood transfusions and operations such as C-sections) provided by physicians, mid-
wives, nurses, paramedical, and support staff at a district hospital (or in a referral ter-
tiary facility). Emergency Obstetric Care (EmOC) represents the minimum amount of
interventions needed to appropriately manage obstetrical complications. This includes
surgical obstetrics (C-sections, treatment of lacerations, laporotomy), anesthesia, medi-
cal treatment of shock, eclampsia and anemia, blood replacement, manual procedures,
and assisted delivery.
Please note that the actions and activities described at each level are the ideal. The actual
level and quality of care offered at various facility types varies widely by country and by
region within countries.
What is the Purpose of the Compendium?

The purpose of the Maternal and Newborn Standards and Indicators Compendium is to
assist program designers to select the essential components and actions for their chosen
interventions (from the “Standards of Care and Recommended Practices” columns in the
tables) and to select appropriate indicators (from the “Indicators” columns in the tables).
The Compendium may also be helpful to those who need to know the standards of care
to assess program effectiveness through monitoring and evaluation, and for those who create
protocols and tools (such as job aids and checklists) for service delivery. In addition, the
2 Maternal and Newborn Standards and Indicators Compendium

Compendium may assist policy makers to know what standards of care and recommended
practices to include when drafting policy documents.
How Can the Compendium of Standards and

Indicators Be Used?
Once an overall framework for a program is selected, and the objectives identified, program
designers may use the Compendium in the following ways:
• To learn more about what are the recommended practices and standards of care for
maternal and newborn health
• To help determine what components of the recommended practices and standards of
care should be incorporated into the program design and into project activities
• To select appropriate indicators that relate to the standards (or develop their own after
considering the indicators that are presented)
• To identify the key indicators (highlighted)
• To identify the most common data sources for constructing the indicators
• To learn more about technical interventions relating to maternal and newborn care
• To identify references and sources supporting evidence-based practices
In each of the five tables, for each of the four levels of care, there is a set of interrelated
standards and indicators.
The standards are recommended essential
components and actions to be included in pro- Why reduction in the Maternal
grammatic interventions. The standards may Mortality (Ratio or Rate) is not an
be considered ‘best practices’ based upon the indicator typically used in NGO pro-
current expert opinion. Not all of the stan- grams designed to reduce maternal
dards presented are evidenced-based, because mortality:
not all of the recommended essential actions
have been scientifically tested or proven. In • Maternal mortality is a relatively rare event.
selecting the standards to be addressed by your The actual number of maternal deaths in a
program, consider the following: particular place and time is relatively small,
• Which most closely align with my program so very large populations must be surveyed
priority? to get estimates.
• Which reflect national policies and
protocols? • Maternal mortality is typically underreport-
• Which are most practical, given the ed, maternal deaths are often misclassified,
context? and methods used to calculate maternal
The indicators are measurable statements of mortality are complex and costly to use.
program objectives and activities. Indicators
are used to measure program process and
progress towards desired program results. The
majority of the indicators presented in the Compendium are illustrative, and may be used ‘as
is’ or be modified depending upon the programmatic objectives and population of interest.
The key indicators are highlighted throughout the Compendium, and are found together
and defined in Appendix 1. This short list of key indicators are the most important indica-
tors to collect, as they are standardized, widely used, and can be readily used to compare
results among programs.
Introduction 3
Most of the indicators in the Compendium identify a means of verification (MOV)—a
data source from which to gather data to construct the indicator. The MOVs include, but
are not limited to, the following data sources:
• Population-based household surveys such as a KAP or KPC survey (Knowledge,
Attitudes, and Practices (or Coverage) Surveys)
• Community Assessments
• Health Facility Assessments (HFA)
• Ministry of Health (MOH) statistics
• HF (Health Facility) statistics
• Health Management Information System (HMIS) (project data)
• Exit Interviews
• Focus groups
• In-depth interviews
Note: Several tools used by many international NGOs, including the KPC 2000+ Survey, are
available on the Child Survival Technical Support Project (CSTS+) web site at: http://www.
childsurvival.com/kpc2000/kpc2000.cfm.
The endnotes, located at the end of each of the five tables, provide detailed technical
information and are directly linked (by numbers) to the main standards and indicators
tables.
Additional information and references relating to designing programs for maternal and
newborn health can be found in Appendix 2. Topics include using frameworks for program
design, program planning, needs assessments, and the causes of maternal and newborn
mortality and evidenced-based interventions. Essential References and helpful web sites are
also included.
Future Editions of this Compendium

The document that you are holding is unique because it provides NGOs with a single source
to find information 1) to determine recommended practices and standards of care at the
household and community levels to address maternal and newborn care, and 2) to identify
what indicators are appropriate to use with community-based maternal health and newborn
programs.
Although this Compendium focuses on the provision of care for mothers and their new-
borns, many NGOS work at the local, district and national levels to improve policies that
affect health. Although the policy level is not explicitly included in the current edition of
the Compendium, it is hoped that in possible future editions of this document that a policy
level will be included.
We hope to improve the Compendium by asking those who use it to provide CORE with
feedback about its relevance, usefulness, and accuracy. We also wish to learn about what we
can include in a future edition that would make the Compendium more useful.
Please send any comments or suggestions about this Compendium to contact@coregroup.
org. Additional information about CORE can be found at www.coregroup.org.

Intervention Focus: Pre-conception/Inter-conception Care [PC]
RECOMMENDED PRACTICES AND
STANDARDS OF CARE INDICATORS
HH
Household Level (PCHH): Provides Security, Support, Safety and Self-Esteem 2 to girls (<5 years old), female youth (ages 5–18) and Women of
Reproductive Age (WRA ages 15–49)
PCHH S-1. Girls, female youth, and WRA get PCHH I-1. Percent of boys and girls age 0–23 months who are underweight (-2 SD from the median weight-
adequate food and micronutrients for appropriate for-age, according to the WHO/NCHS reference population)* (Means of Verification [MOV]: population-
growth.3 based survey)
Key Indicator Definition: Numerator: Number of children age 0–23 months whose weight is –2 SD from the
median weight of the WHO/NCHS reference population for their age.
Denominator: Number of children age 0–23 months in the survey who were weighed (If there is reason to
believe that girls are fed differently than boys, then compute a ratio of malnutrition [girls to boys] using the
data collected.)
PCHH I-2. Percent of WRA living in households using adequately iodized salt**
(MOV: population-based survey)
PCHH I-3. Percent of WRA who have a low body mass index**
PCHH I-4. Percent of WRA with a low mid-upper arm circumference*
PCHH I-5. Percent of WRA with anemia**
(MOV: population-based survey or surveillance)
PCHH S-2. Girls receive appropriate care when ill. PCHH I-6. Percent of sick girls age 0–23 months who received increased fluids and continued feeding during an ill-
ness in the past two weeks*
PCHH I-7. Percent of mothers of girls age 0–23 months that recognize at least two danger signs of child illness*:
• Looks unwell or not playing normally
• Not eating or drinking
• Lethargic or difficult to wake
• High fever
• Fast or difficult breathing
• Vomits everything
• Convulsions
Maternal and Newborn Standards and Indicators Compendium
5

HH
PCHH S-3. Girls, female youth and WRA live and PCHH I-8. Percent of caregivers that can state what GBV means
work in a safe environment, including protection (MOV: population-based survey; client exit interview)
from gender based violence (GBV) (female genital
PCHH I-9. Percent of children (girls) age 0–23 months who slept under an insecticide-treated net (in malaria risk
cutting [FGC], child and sexual abuse, domestic
areas) the previous night*
violence), smoking, alcohol, and environmental
hazards.4
PCHH I-10. Percent of WRA (or subset) not exposed to smoking, alcohol, and environmental hazards, including
GBV in past year
(MOV: population-based survey; youth survey)
PCHH I-11. Percent of WRA allowed to go alone to the health center**
PCHH I-12. Participation of women in household decision-making index**
PCHH I-13. Percent of WRA who have weekly exposure to mass media**
PCHH I-14. Percent of youth who regularly use drugs/alcohol
(MOV: youth survey)
6
HH
PCHH S-4. Girls attend school at least through pri- PCHH I-15. Ratio of girls to boys in primary schools in catchment area
mary school education.5 (MOV: school records)
In regions with high primary school completion, we PCHH I-16. Percent of WRA who have completed at least four years of schooling**
would recommend using ‘secondary school’ in the (MOV: population-based survey)
standard. Key Indicator Definition: Numerator: #of women ages 15–49 who completed four years of schooling;
Denominator: Total # of women ages
15–49
This indicator measures the percent of women ages 15–49 who have completed at least a primary level of educa-
tion. For different countries, primary education may vary from four years to eight to ten years.
PCHH S-5. Girls delay marriage/childbirth to the age PCHH I-17. Percent of WRA married in the past year that were 18 years or older at the time of marriage7
of 18.6 (MOV: population-based survey; marriage registry)
PCHH S-6. Girls and boys get information on sexual PCHH I-18. Percent of girls and boys who can state:
and reproductive health issues8 including protection • Two benefits to delaying marriage and childbirth
from unintended pregnancy (family planning9) and • Two ways to avoid pregnancy
HIV/AIDS.10 • Two ways to prevent HIV/AIDS
(MOV: youth survey)
7

HH
PCHH S-7. Youth practice safe sex and avoid unin- PCHH I-19. Percent of sexually active youth who used a condom at first/last sexual intercourse**
tended pregnancy and sexually transmitted infec- (MOV: youth survey)
tions (STIs).
PCHH I-20. Percent of sexually active youth who used contraception at last intercourse
(MOV: youth survey)
PCHH I-21. Percent of youth that abstain from sexual intercourse
(MOV: youth survey)
PCHH I-22. Number of sexual partners among sexually active youth during the past six months** (MOV: youth
survey)
PCHH I-23. Number/percent of youth who have experienced coercive or forced sex**
(MOV: youth survey)
PCHH S-8. WRA practice birth spacing. PCHH I-24. % of women married or in union 15–49 years who are not pregnant or are unsure, who are using a
modern family planning method***
PCHH I-25. Percent of mothers who report at least one place where she can obtain a method of family planning*
PCHH I-26. Percent of children aged 0–23 months who were born at least 24 months after the previous surviving
child*
PCHH I-27. Percent of mothers who received family planning information during a postpartum check-up*
8

C Community Level (PCCL): Monitors health status of girls and boys, youth, and WRA; helps households with environmental issues.
PCCL S-1. Community Health Workers (CHWs)/ PCCL I-1. Percent of CHWs/community leaders that recognize at least two danger signs of child illness:
community leaders monitor health status of both • Looks unwell or not playing normally
girls and boys in the community, recommend stan- • Not eating or drinking
dards of care and refer for care when needed. • Lethargic or difficult to wake
• High fever
• Fast or difficult breathing
• Vomits everything
• Convulsions
(MOV: community assessment)
PCCL I-2. Percent of trained CHWs serving the community appropriately
(MOV: CHW supervisory records)
PCCL S-2. CHWs/community leaders promote and/ PCCL I-3. Percent of CHWs/community leaders who can state 3 ways to ensure a safe environment for WRA.
or have policies to ensure a safe environment for (MOV: community assessment)
WRA:
PCCL I-4. Percent of households of mothers with children age 0–23 months that have soap readily available for hand-
Develop and/or support clean water supply and use washing.*13
of latrines11 (MOV: population-based survey)
• Discourage and have disciplinary action for
persons who commit GBV12, (domestic vio- PCCL I-5. Percent of families with functional latrines
lence, child and sexual abuse) (MOV: population-based survey)
• Identify and monitor for environmental haz- PCCL I-6. Percent of CHWs/community leaders who support anti-smoking and no use of alcohol by youth
ards such as toxic waste (MOV: community assessment)
• Actively support anti-smoking programs and
no use of alcohol by youth See also PCHH I-10, I-14
9

C Community Level (PCCL): Monitors health status of girls and boys, youth, and WRA; helps households with environmental issues.
PCCL S-3. Community leaders ensure the avail- See PCHH I-15, I-16
ability of schools and encourage parents to send all
girls and boys to school
PCCL S-4. CHWs/community leaders openly sup- PCCL I-7. Percent of villages with leadership that supports girls delaying marriage until age 18.
port and encourage delayed marriage (after 18 (MOV: community assessment)
years) for the health and well-being of WRA and
families See also PCHH I-17
PCCL S-5. Community leaders recognize the PCCL I-8. Percent of community leadership positions held by women
importance of women and their contributions to the (MOV: community assessment)
community
PCCL S-6. CHWs/community leaders provide coun- PCCL I-9. Percent of CHWs/community leaders providing counseling and education on pregnancy,
seling and education on pregnancy, birth planning birth planning and STIs
and STIs14 (MOV: community assessment, CBDA records)
10

First Level (PCFL): Works with community-based distribution agents (CBDAs), community leaders, teachers, religious leaders to promote the
1 health of girls, and discourage violence, abuse and body mutilation including FGC15; provides ‘youth friendly’ reproductive health services and
referral
PCFL S-1. Health facility personnel support and PCFL I-1. Percent of facilities screening for GBV
promote the health of girls, female youth, and (MOV: Health Facility Assessment (HFA) /checklist JHPIEGO/IPPF)
WRA:
PCFL I-2. Percent of facilities providing care for GBV in non-judgmental manner
(MOV: HFA /checklist JHPIEGO/IPPF)
• Screen for and treat malaria and infectious
diseases16 PCFL I-3. Percent of clients satisfied with services provided
• Screen for and treat malnutrition and ane- (MOV: client satisfaction survey; client exit interviews)
mia17
PCFL I-4. Percent of facilities that provide ‘youth-friendly’ services
• Screen for GBV, including sexual and child
(MOV: HFA)
abuse and FGC
• Treatment and follow-up for congenitally or PCFL I-5. Percent of staff trained to work with and provide services to youth**
birth-acquired, as well as sexually-acquired, (MOV: HFA)
STIs (gonorrhea, chlamydia, syphilis)
• Health education PCFL I-6. Percent of youth aware of ‘youth-friendly’ health services**
• Provide ‘youth friendly’ reproductive health (MOV: youth survey)
services,18 including education/information PCFL I-7. Percent of youth served or reached by the ‘youth friendly’ services**
and contraception, and promote the use of (MOV: health facility records)
dual protection19 family planning for sexually
active WRA in order to delay pregnancy until PCFL I-8. Percent of female youth/WRA who can explain dual protection
at least 18 years of age (MOV: youth survey)
PCFL I-9. Percent of facilities exhibiting gender sensitivity in the service delivery environment**
(MOV: HFA)
See also PCHH I-1 – I-10, I-14, I-17 – I-27
11

referral
PCFL S-2. Health facilities are prepared to provide PCFL I-10. Percent of facilities prepared to provide the essential services**
the essential services20 (MOV: HFA, including interviews with staff and facility inventory of equipment and supplies)
PCFL S-3. Health facility personnel work with PCFL I-11. Number of school visits by health facility personnel per year
teachers at public, private and religious schools to: (MOV: school and health personnel management records)
• Support girls from 10–24 years to continue in
PCFL I-12. Percent of schools with active peer discussion groups
school
(MOV: school records)
• Promote good nutrition through development
of school gardens, consumption of locally PCFL I-13. Percent of students who pass school examination on sexual and reproductive health issues
available foods, and micronutrient supplemen- (MOV: school records)
tation
• Share accurate basic sexual and reproductive PCFL I-14. Percent of schools with school gardens
health information (MOV: school assessment)
• Hold peer discussion groups on body changes; PCFL I-15. Percent of schools providing micronutrient supplements to at-risk youth
sexuality; GBV; prevention of: pregnancy, (MOV: school records; health facility records)
sexually transmitted infections (STI), and HIV/
AIDS See also PCHH I-14 – I-23
• Provide periodic assessments and IEC with
a focus on malnutrition, infectious diseases,
GBV
In areas where children do not have access to
school:
Health facility personnel work with community
leaders and youth groups to support literacy
training.
12
referral
PCFL S-4. Clinic personnel identify WRA approaching marriage age or 1-2 PCFL I-16. Percent of girls/young WRA of marriage age provided services and support by clinic
years younger and provide the following services and support: personnel
• Nutrition (including micronutrients and/or multivitamin supplements) (MOV: health facility records)
counseling to young WRA and parents/caretaker/ husband-to-be:
PCFL I-17. Percent of female youth/WRA who are anemic
– Need for nutritious food and adequate weight of woman/ mother
(MOV: HF records)
for healthy pregnancy and infant survival
– Encourage the regular intake of iron/folate tablets PCFL I-18. Percent of anemic female youth/WRA who are given iron/folate tablets
• Monitor for GBV and provide counseling regarding abuse and its devas- (MOV: HF records)
tating affects on women, infants and families PCFL I-19. Percent of WRA who cite at least two known ways of reducing the risk of HIV
• FP counseling and services including the importance of pregnancy delay infection*
until at least 18 years (MOV: population-based survey; client exit interview)
• Health education on STIs and HIV/AIDS prevention21
• Education and support for living and working in a safe environment PCFL I-20. Percent of facilities offering three or more modern FP methods
including protection from gender violence (domestic violence and sexual (MOV: HFA)
abuse), smoking and alcohol, environmental hazards See also PCHH I-10, I-19 – I-23; PCFL I-1 – I-9
PCFL S-5. Establishes and promotes the use of a “marriage visit” by young PCFL I-21. Percent of young married couples who attended a “marriage visit”
couples that would include: (MOV: health facility records)
• Adequate food intake and iron/folate for WRA prior to and during PCFL I-22. Couple-years of protection**
pregnancy, and during breastfeeding (MOV: service statistics or MIS)
• Physical exams focusing on nutritional status, reproductive health,
STIs, HIV/AIDS22 PCFL I-23. Percent of young couples who state the reason to delay pregnancy until after 18
• Other topics listed in PCFL S-4. years old
(MOV: client exit interview)
PCFL I-24. Unmet need for family planning**
PCFL S-6. Health facilities provide post-abortion care23. PCFL I-25. Percent of facilities providing post-abortion care**
(MOV: HFA)
PCFL I-26. Percent of practitioners trained in PAC**
(MOV: HFA)
PCFL I-27. Percent of health facilities that offer family planning to PAC patients**
(MOV: HFA)
13

Second Level (PCSL): Promotes the health of girls, female youth, and WRA, and their education, awareness of issues in reproductive health, vio-
2
lence, abuse and body mutilation including FGC, and provide nonjudgmental care.
PCSL S-1. Apply PCFL S-1 to the hospital and out- PCSL I-1. Percent skilled health workers providing comprehensive care
patient clinics (MOV: supervisory records; HFA)
See also PCFL I-1 – I-9; PCHH I-1 - I-10, I-14, I-17 – I-27
PCSL S-2. Provide in-service training for facility PCSL I-2. Percent of facility staff and area health workers receiving in-service training on the care of female youth and
staff and other area health workers on the care of WRA prior to pregnancy
female youth and WRA prior to pregnancy (MOV: health facility records)
PCSL I-3. Percent of staff and area health workers who distribute iron/folate to girls/young WRA
(MOV: supervisory records)
* Source: taken directly or derived from KPC 2000+; CSTS, CORE.

** Source: taken directly or derived from Bertrand J and Escudero G. Compendium of Indicators for Evaluating
Reproductive Health Programs. MEASURE Evaluation: 2002.
*** Source: Flexible Fund Family Planning Guidance; USAID, 2004.
14
Endnotes
1. “Main interventions to be available to women and men of reproductive age include nutrition
education . . . family planning . . . prevention and treatment of sexually transmitted infections
[including HIV/AIDS], and general health services to enhance knowledge and understanding
of their bodies.” Promoting Quality Maternal and Newborn Care: A Reference Manual for
Program Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE),
Chapter 5.
Pre-pregnancy care
• Education for girls

o Higher levels of schooling for girls and women are correlated with increased obstet-
ric survival.
• Reducing prevalence of female genital cutting (FGC)
o Conducting community-wide education and creating alternative rituals for FGC can
reduce the risks of maternal morbidity and stillbirths.
• Delivering micronutrient supplementation through schools
o Iron supplementation delivered through the school and targeted to at-risk adoles-
cents is an effective way to prevent anemia and iron deficiency.
• Providing multivitamins prior to conception can improve maternal health
o Combined supplements prior to conception are more effective than single supple-
ments.
• Starting smoking cessation programs in adolescence
o Smoking cessation education programs for adolescents can be effective in preventing
tobacco use.
• Providing family planning
o Access to a choice of safe, affordable, and appropriate family planning knowledge
and methods, especially for adolescents, is essential to ensuring safe motherhood by
reducing unwanted pregnancies.
o Also refer to the forthcoming module on Reducing Unintended Pregnancy.
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 85-94.
2. All girls and young women need ‘security’, which includes food, shelter and clothing; ‘support’,
which includes schooling, health care, etc.; ‘safety’, which includes protection from unsanitary
living conditions, domestic/child/sexual abuse, smoking and alcohol, and environmental and
occupational hazards such as use of pesticides, poisonous materials; ‘self-esteem’, which includes
decision-making, having choices in life and belief in the possibility of a healthy, happy and safe
future for herself and her family.
3. “Girls are often underfed and their malnutrition is closely linked with low women’s status and
societal norms.” “…Emphasis should be placed on improving pre-pregnancy weights (of
girls) so that women do not enter pregnancy in a nutritionally disadvantaged state.” “The
combination of low pre-pregnancy weight and pregnancy weight gain has detrimental effects on
infant outcomes. An estimated 450 million adult women in the developing world are stunted
(short for their age) resulting from chronic protein-energy malnutrition throughout their lives.
Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers.
(1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE) Chapter 2.
“If weights are known before or early in pregnancy, a low weight for height of 10 percent
or more below reference can be a rough indicator of undernutrition.” “When caloric
Intervention Focus: Preconception/Inter-Conception Care 15

supplementation was given to women with low pre-pregnancy weight and low caloric intake
(under 1700 calories), the percentage of low birth-weight infants decreased significantly, and the
viability of the infants increased. Mother and Child Health: Delivering the Services. Williams, C.
Baumslag, N. Jelliffe, D.B. 1994 Chapter 6.
The most common micronutrient deficiencies to monitor for are iron, folic acid, vitamin A and
iodine. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE) Chapter 2.
Check local or national guidelines regarding adequate nutrient intake.
Energy requirements differ from place to place because of variance in body weight and activity
levels.
King FS and Burgess A, Nutrition for Developing Countries, second edition. Oxford University
Press, Oxford: 1988. p. 426–7.
“Increasing food intakes for girls until three years of age may increase their adult height and
decrease risk of maternal mortality.” Gay J, Hardee K, et al. What Works: Safe Motherhood.
Policy Project, Washington: 2003, p. 78.
4. “ In some societies, women are responsible for cloth dying and weaving in factories and are
susceptible to bladder cancer from the aniline dyes used. They are also at risk from dust
diseases. Women in agriculture exposed to insecticides or herbicide sprays are at risk of such
disorders as sterility, stillbirths, and congenital defects in their offspring.” Girls who are growing
and developing are at even greater risk. Mother and Child Health: Delivering the Services.
Williams, C., Baumslag, N., Jelliffe, D.B. 1994 Chapter 6, pg. 94.
“Averting exposure by women of reproductive age to high-level polychlorinated biphenyls
(PCBs) may reduce the numbers of stillbirths.” Gay J, Hardee K, et al. What Works: Safe
Motherhood. Policy Project, Washington: 2003, p. 60.
“Decreasing exposure to pesticides may reduce the numbers of spontaneous abortions…A study
in Canada found strong evidence that women’s exposure to pesticides in the three months prior
to conception or in the month of conception significantly increased their risk of spontaneous
abortion.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington:
2003, p. 61.
5. UNICEF points out in its Programming for Safe Motherhood: Guidelines for Maternal and
Neonatal Survival (1999) that it is important to increase girls’ access to education. “There is a
clear relation between girls’ access to education and literacy and reduced maternal mortality.
Pg. 26 “Of the 130 million children who are not attending primary school in the developing
world, 60 percent are girls. Of the estimated 960 million people who are illiterate, 66 percent
are women. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE) Chapter 2.
6. “. . . Age at marriage is closely linked to first birth due to cultural norms and expectations,
and due to the fact that contraception is less commonly used to delay first births than it is to
delay later births. Where women marry later, they have more time to complete their education,
learn about reproduction and contraceptive methods and develop marketable skills. Moreover,
delayed marriage and first birth means fewer years spent in childbearing, and is often linked
to lower total fertility.” Due to physiological and social factors, girls/young women are more
vulnerable than older women to pregnancy-related complications; sexually transmitted diseases
(infections), including HIV/AIDS; and unsafe abortion. Safe Motherhood Fact Sheet—Safe
Motherhood Inter-Agency Group (IAG) 1998 Girls aged 15–19 are twice as likely to die from
childbirth as women in their twenties. The Safe Motherhood Action Agenda: Priorities for the
Next Decade. Report on the Safe Motherhood Technical Consultation, 18–23 October 1997
Colombo, Sri Lanka
7. The appropriate age of marriage will vary by place, according to culture and custom.
8. Facts about reproductive health issues of girls/young women: Nearly half of the world’s

population is under age 25. Adolescents account for approximately 10 percent of all births
worldwide. Each year 15 million girls ages 15-19 have babies. Girls under 16 years old are
twice as likely to die in childbirth as women in their early twenties. Two to four million
adolescents in developing countries have unsafe abortions each year. Nearly half of all HIV
infections worldwide occur in people under age 25. Seven in 10 new sexually transmitted
infections (STIs) occur among individuals 15-24 years old. Meeting the Needs of Young Clients:
A Guide to Providing Reproductive Health Services to Adolescents, Family Health International,
2002 available at www.fhi.org
Adolescents account for 21 percent of all maternal deaths. Promoting Quality Maternal and
Newborn Care: A Reference Manual for Program Managers. (1998). Cooperative for Assistance
and Relief Everywhere, Inc. (CARE) Chapter 2
9. “Enabling couples to determine whether, when, and how often to have children is vital to safe
motherhood and child health. By limiting births, preventing closely spaced births or births to
very young or old mothers, infant, child and maternal mortality can be reduced.”
“Family planning encompasses a full range of modern methods, both temporary and permanent.
Modern methods include condoms (male and female) and other barrier methods (diaphragms,
cervical caps), pills, injectables, intrauterine devices (IUDs), implants (Norplant), voluntary
surgical sterilization (male or female). Lactation Amenorrhea Method (LAM) and the Standard
Days Method (SDM) are modern natural methods. Emergency contraceptives are methods of
preventing pregnancy after unprotected sexual intercourse. Emergency contraception can be
used when a condom breaks, after a sexual assault, or any time unprotected sexual intercourse
occurs. However, emergency contraception does not protect against sexually transmitted
infections. Most women can be safely offered emergency contraception (EC) in advance of need
to have it available when it is needed.”
Two quotes above from: USAID CSHGP, Technical Reference Materials (TRMs); Family
Planning Module. 2004: pages 7 and 11, respectively.
“Access to affordable, high-quality family planning services is one of the most important
interventions to reduce maternal mortality . . . Reducing unwanted pregnancies and unsafe
abortions can have major impacts on reducing maternal mortality.” Gay J, Hardee K, et al.
What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 87.
“It is estimated that 67,000 women die annually worldwide following complications of
abortion. This accounts for a considerable portion (10% to 50%, depending on the country)
of all maternal deaths. Many of these deaths could be prevented if women were able to avoid
unwanted pregnancies, and had access to safe abortions and post-abortion care. Complications
due to abortion can be prevented, and a substantial reduction in maternal deaths can be
achieved if complications are recognized early and treated appropriately.” USAID CSHGP,
Technical Reference Materials (TRMs); Maternal and Newborn Care Module 2004: p. 18
10. “Women’s relative lack of decision-making power, education, and economic independence in
many parts of the world affects their ability to both protect themselves from HIV infection and
seek and receive treatment and support. According to United Nations figures… young women
in the region [Sub-Saharan Africa] are now 6 times more likely than young men to be infected;
women, in general, die faster from the disease then men.” Kiragu, K. (2001). Youth and HIV/
AIDS: Can we avoid catastrophe? Population Reports. Series L (12).
11. “ A high prevalence of fever, diarrhea, and infectious parasitic and debilitating diseases is
commonly associated with poor sanitation.” These acute and chronic diseases cause the
women to use more calories and lose protein and other nutrients, making their malnutrition
or undernutrition worse. Mother and Child Health: Delivering the Services. Williams, C.,
Baumslag, N., Jelliffe, D.B. 1994 Chapter 6, pg. 98
12. Gender violence is defined as any act of violence that results in or is likely to result in physical,
sexual, or psychological harm or suffering to women, including threats of such acts and/or
coercion or arbitrary deprivations of liberty, taking place in public or private life. Violence

against women across the lifespan includes: Pre-birth: sex-selective abortion; effects of
battering during pregnancy on birth outcomes; Infancy: female infanticide; physical, sexual
and psychological abuse; Girlhood: child marriage; female genital mutilation (FGM); physical,
sexual and psychological abuse; incest; child prostitution and pornography; Adolescence and
Adulthood: dating and courtship violence (e.g. acid throwing and date rape); economically
coerced sex (e.g. school girls having sex with “sugar daddies” in return for school fees); incest;
harassment; forced prostitution and pornography; dowry abuse and murders; partner homicide;
psychological abuse; abuse of women with disabilities; forced pregnancy). Programming for Safe
Motherhood: Guidelines for Maternal and Neonatal Survival. UNICEF (1999) pg. 109–110
13. Washing hands at appropriate times is one of the most important ways of preventing the
spread of disease. WHO and UNICEF have acknowledged appropriate handwashing as a key
family practice to improve child health and nutrition in communities. Because handwashing
cannot be observed directly in most household surveys and mother’s recall of appropriate time
of handwashing reflects actual practice poorly, the observation of the presence of soap in a
place where handwashing is usually done is suggested as a more objective measure. Studies
have shown that the presence of soap is related to health outcomes such as diarrhea. In many
countries most households will have soap, but not necessarily readily available for handwashing.
This is the reason for first asking the interviewee to see the place where hands are usually
washed and what is used for handwashing.
14. HIV/AIDS prevention before pregnancy includes: (a) community awareness and mobilization
including lessen the stigma surrounding voluntary testing, (b) dispel local myths such as that
sex with a virgin will cure the disease or that condoms contain HIV, (c) link prevention to care
and support. Israel E and Kreger, M. 2003. Integrating Prevention of Mother to Child HIV
Transmission into Existing Maternal, Child, and Reproductive Health Programs. Technical
Guidance Series, Pathfinder International, Watertown. www. Pathfind.org
15. FGC = female genital cutting
16. Screening and treatment for malaria and hookworm infection are especially important because
these diseases/infections significantly contribute to anemia and malnutrition—major reasons
why young women enter pregnancy in poor health and under-weight or malnourished. Malaria
substantially increases the risks of maternal anemia, prematurity and low birth-weight during
a woman’s first pregnancy. Programming for Safe Motherhood: Guidelines for Maternal and
Neonatal Survival (1999) pg. 52 and 54
Malaria in Africa is estimated to cause up to 15% of maternal anemia and 35% of preventable
low birth-weight. Lives at Risk: Malaria and Pregnancy. SARA project funded by USAID
17. Decreasing anemia in young women through good nutrition and iron/folate tablets is important
for their health and for their future childbearing. Women need three times more iron than
men. Maternal death rates are five times higher in anemic than in non-anemic women. WHO
reported that half of pregnant and more than a third of nonpregnant women are anemic.
Mother and Child Health: Delivering the Services. Williams, C. Baumslag, N. Jelliffe, D.B. 1994
Chapter 6, pg. 101.
Folic acid supplementation prior to pregnancy can reduce the risk of neural tube defects by
more than two thirds. Recommendations are: 0.4–.08 mg/day beginning at least one month
prior to conception and continuing through the first trimester. This amount is increased to 4
mg for women with a history of a prior pregnancy affected by a neural tube defect. Barash, J.
Weinstein, LC, Preconception and prenatal care, Primary Care Clinical Office Practice (journal),
29(2002) 519–542
18. ‘Youth friendly’ services “have policies and attributes that attract adolescents to the facility
or program, provide a comfortable and appropriate setting for youth, meet the needs of
adolescents, and are able to retain their adolescents for follow-up and repeat visits” (Senderowitz,
1999; as quoted in Bertrand J and Escudero G. Compendium of Indicators for Evaluating
Reproductive Health Programs. MEASURE Evaluation: 2002, p. 374.) “Aspects of an ‘adolescent
friendly’ environment can include space or rooms dedicated to adolescent reproductive health

services, policies and procedures to ensure privacy and confidentiality, peer educators on
site, nonjudgmental staff, and acceptance of drop-in clients” (also MEASURE Evaluation,
Compendium . . . ).
19. “Dual protection – Offering condoms to prevent the spread of STIs and HIV should be routine
in family planning and STI clinics. The idea of using condoms in addition to another family
planning method choice, or using only condoms, may be new to clients. Counseling on the
importance of dual protection, as well as on the necessary skills to implement dual protection
effectively, is a necessary part of HIV/AIDS prevention.” Israel, E and Kroeger, M. 2003.
Integrating Prevention of Mother-to-Child HIV Transmission into Existing Maternal, Child, and
Reproductive Health Programs. Technical Guidance Series, Pathfinder International, Watertown.
20. Services include family planning, STIs, maternal health and child health. (Bertrand J and
Escudero G. Compendium of Indicators for Evaluating Reproductive Health Programs.
MEASURE Evaluation: 2002, p. 169)
21. It is important to provide information on STIs and HIV/AIDS to young women and men.
Additionally, IEC strategies should address delay of sexual debut (first experience with sexual
intercourse), sexually transmitted infection prevention and safer sex, voluntary confidential
counseling and testing (VCCT), and basic facts of HIV/AIDS… IEC efforts can contribute
to prevention and to the de-stigmatization of HIV/AIDS . . . The majority of women are not
infected and they need services and care to help them stay that way. Israel, E and Kroeger, M.
2003. Integrating Prevention of Mother-to-Child HIV Transmission into Existing Maternal,
Child, and Reproductive Health Programs. Technical Guidance Series, Pathfinder International,
Watertown. www.pathfind.org
“Youth as a special focus: explore ways to reach young women and men with HIV information
in schools, at the market, at football matches, on the job, on the street, and in youth-friendly
counseling, which has shown to be valued by youth.” Macquarrie, K. 2001. Making VCT more
youth-friendly: Designing services to reach young people. Horizons report: Operations research
on HIV/AIDS.
22. Voluntary testing before marriage has been promoted in Uganda and is suggested for other high
prevalence countries.
23. Post-abortion care (PAC) “generally includes clinical treatment for complications of incomplete
abortion, provision of counseling and contraceptive supplies (to avoid repeat abortion), and in
some locations, referral to other reproductive health care. PAC may also include community
education to improve reproductive health and to reduce unwanted pregnancy and the need for
abortion.” Bertrand J and Escudero G. Compendium of Indicators for Evaluating Reproductive
Health Programs. MEASURE Evaluation: 2002, p. 397.

Intervention Focus: Antenatal Care1 [AC]
HH
Household Level (ACHH): The Household2 prepares for birth and is ready for complications, including accessing essential and emergency care
during pregnancy, identifying danger signs, and establishing a supportive environment for the pregnant woman.
ACHH S-1. Family plans for the use of a skilled ACHH I-1. Percent of pregnant women receiving ANC who have a birth plan (including use of a skilled
provider at birth. provider at birth)
(Means of Verification [MOV]: HF records; population-based survey; ANC client survey or exit interview)
ACHH S-2. Pregnant woman seeks antenatal care3 ACHH I-2. Percent of pregnant women/family in catchment area who can state the benefits of antenatal care
four times during an uncomplicated pregnancy from (MOV: population-based survey; ANC client survey or exit interview)
a skilled provider when:
ACHH I-3. Percent of mothers of children aged 0-23 months in catchment area that saw a skilled provider three
• Pregnancy first suspected (before end of 16 or more times during last pregnancy*
weeks) (MOV: population-based survey; HF records)
• Between 24 and 28 weeks
• At 32 weeks Key Indicator Definition: Numerator: number of mothers of children aged 0-23 months in catchment area that
• At 36 weeks saw a skilled provider three or more times during last pregnancy. Denominator: number of mothers of children
aged 0–23 months.
ACHH S-3. Household-level use of key ANC inter- ACHH I-4. Percent of women receiving ANC who can name two local dietary sources of iron
ventions: (MOV: population-based survey; HF records)
• Nutrition4: take iron/folate5, vitamin A6 (in ACHH I-5. Percent of mothers who received/bought iron supplements while pregnant with the youngest child less
areas of endemic vitamin A deficiency); eat an than 24 months of age*
extra meal; drink 6–8 cups liquids daily7 (MOV: population-based survey; HF records; ANC client or exit interview)
• Rest daily8
• Practice safer sex ACHH I-6. Percent of pregnant women who gain at least 1kg per month in the last two trimesters of pregnancy
• Malaria prevention and management in areas (MOV: HF records)
of endemic malaria
ACHH I-7. (In malaria endemic area) Percent of women receiving ANC who took two or more doses of IPT
• Hookworm prevention/treatment9 in areas of
(MOV: population-based survey; HF records)
endemic hookworm
• TB prevention and treatment10 ACHH I-8. (In malaria endemic area) Percent of women using ITNs
• Safe environment (including protection from (MOV: population-based survey)
GBV, smoking11, alcohol, and environmental
ACHH I-9. Percent of women attending ANC who cite at least two known ways of reducing the risk of HIV
hazards12)
infection
(MOV: ANC client survey or exit interview; HF records)
21
HH
ACHH I-10. Percent of pregnant women who receive antihelminthic treatment ***
(MOV: population-based survey; HF records; ANC client or exit interview)
ACHH I-11. Percent of women attending ANC who receive vitamin A supplementation (in areas of endemic vitamin
A deficiency)
(MOV: population-based survey; HF records; ANC client or exit interview)
ACHH I-12. Percent of pregnant women with TB who complete treatment
(MOV: HF records)
ACHH S-4. Pregnant woman and family recognize ACHH I-13. Percent of women/families receiving ANC who can state four danger signs of pregnancy
and act appropriately on the danger signs of (MOV: population-based survey; HF records; ANC client survey or exit interview)
pregnancy14:
• Any bleeding15
• Swelling of hands/face and severe headache16
• Fits17
• No fetal movement after 24 weeks18
• Fever19
• Severe pain in abdomen or when passing
urine20
ACHH S-5. Pregnant woman and household make ACHH I-14. Percent of women/families who have chosen feeding option for baby
plans for normal and complicated birth.21 (MOV: population-based survey; HF records; ANC client survey or exit interview)
• Planning for normal delivery22 (travel and ACHH I-15. Percent of women/families receiving ANC who have prepared clean birthing kit / necessary supplies for
lodging to facility with skilled provider, or birth
clean birth kit23 for delivery at home) (MOV: population-based survey; HF records; ANC client survey or exit interview)
• Recognition of danger signs and complications
of pregnancy ACHH I-16. Percent women/families who have given birth in past 12 months who report
• Establishing transport plans • use of skilled provider during birth
• Knowing where to go in case of emergency • feeding option chosen before birth
• Money in case of emergency • having, during pregnancy, a plan for what to do in event of danger sign
• Identifying blood donors (MOV: population-based survey; HF records; ANC client survey or exit interview)
• Preparing to breastfeed24 or not if HIV+ Also see ACHH I-13.
mother decides
22

HH
ACHH S-6. Pregnant woman/partner have plans for ACHH I-17. Percent women receiving ANC who report birth spacing plans
birth spacing after birth25, 26 (MOV: population-based survey; HF records; ANC client survey or exit interview)
ACHH I-18. Percent of women who report at least one place where she can obtain a method of family planning*
ACHH I-19. Percent of children aged 0–23 months who were born at least 24 months after the previous surviving
child*
ACHH I-20. Percent of pregnant women who can state two benefits of birth spacing
(MOV: HF records; ANC client or exit interviews)
ACHH I-21. Percent of postpartum mothers who report initiating use of a modern method of FP within six weeks after
birth**
(MOV: population-based survey; HF records; CBDA records)
23

C
Community Level (ACCL): The COMMUNITY facilitates birth preparedness and birth complication readiness at the household
and community levels.
ACCL S-1. Community mobilization (TBAs, CHWs, and ACCL I-1. Percent of TBAs/CHWs/community members interviewed who can state two benefits of pregnancy
other community members) for birth planning, complica- care
tion readiness and education27 including28, 29, 30: (MOV: HF records; community assessment)
• Key household ANC interventions (see ACHH S-3)
ACCL I-2. Percent TBAs/CHWs/community members interviewed who can name four components of birth
• Planning for normal delivery
planning/complication readiness
• Recognize and respond to danger signs in mother
(MOV: HF records; community assessment)
• First aid care in order to stabilize the woman or new-
born with a complication until reaching trained health ACCL I-3. Percent TBAs/CHWs/community members interviewed who can name four danger signs for the
worker woman
• Encourage four ANC visits (MOV: HF records; community assessment)
• PMTCT (in HIV/AIDS-affected areas)
• Family planning and birth spacing ACCL I-4. Percent of TBAs/CHWs/community members interviewed who have knowledge of PMTCT
See other services in endnotes31
Also see ACHH I-4 – I-11
ACCL S-2. Community mobilization for emergency finance ACCL I-5. Percent of communities that have an emergency transport system
scheme, emergency transport scheme, and blood donor (MOV: HF records; community assessment)
pool32
ACCL I-6. Percent of communities that have an emergency financing system
ACCL I-7. Percent of communities that have a blood donor system
ACCL S-3. TBAs/CHWs/community members record preg- ACCL I-8. Percent of TBAs/ CHWs/community members/communities that have a register recording pregnant
nant women and outcomes33 women and outcomes
(MOV: community assessment)
24
RECOMMENDED PRACTICES
AND STANDARDS OF CARE INDICATORS
1 First Level34 (ACFL): Skilled ANC provides for normal pregnancies and manages and/or refers complications.
ACFL S-1. Provide skilled ANC35 ACFL I-1. Percent of women receiving ANC who are counseled and tested for HIV
including: (MOV: population-based survey; HF records; ANC client survey or exit interview)
• Discuss preparation for birth36 ACFL I-2. Percent of women receiving ANC who report being counseled on danger signs; rest and nutrition; safer sex; breastfeed-
• Identify/manage complications37 ing; LAM; birth spacing; protection from environmental hazards
• Provide iron/folate, tetanus tox- (MOV: population-based survey; ANC client survey or exit interview)
oid, vitamin A
• Provide malaria and parasite ACFL I-3. Percent of women receiving ANC who report that partner/family were included in education, birth planning and care
prevention38 and treatment39 (MOV: ANC client survey or exit interview)
according to country protocols
ACFL I-4. Percent of mothers with children age 0–23 months who received at least two tetanus toxoid injections before the birth of
• Screen and manage anemia,
their youngest child*
hypertension, TB, STIs, (provide
essential antenatal laboratory
tests)40 Key Indicator Definition: Numerator: number of mothers with children age 0–23 months who received at least two tetanus toxoid
• Counsel and test for HIV/AIDS41 injections before the birth of her youngest child (confirmed by maternal health card).
• Screen and provide counseling Denominator: Number of mothers with children age 0–23 months.
and referrals for GBV42 and
protection from environmental ACFL I-5. Percent of women with child under 12 months of age who report receiving at least 90 iron tablets during last pregnancy
hazards (MOV: population-based survey)
• Counsel woman and family on ACFL I-6. Percent of service sites where providers encourage participation of partner/family in education, birth planning, and care
danger signs, rest and nutrition, (MOV: population-based survey; HF records; ANC client survey or exit interview)
safer sex, birth spacing, LAM,
ACFL I-7. Percent of facilities screening for GBV in non-judgmental manner
breastfeeding
(MOV: HFA/checklist JHPIEGO/ IPPF)
• Referral system in place for care
not available at first level ACFL I-8. Percent of clients satisfied with services provided
• Encourage involvement of part- (MOV: client satisfaction survey; client exit interviews)
ner/family in education, birth ACFL I-9. Percent of facilities exhibiting gender sensitivity in the service delivery environment***
planning and care (MOV: HFA)
ACFL I-10. Percent of ANC service delivery points with adequate supplies.
(MOV: HFA)
ACFL I-11. Percent of pregnant women receiving ANC who have received hgb/hct and RPR testing
(MOV: HF records)
ACFL I-12. Percent of pregnant women diagnosed with and treated for syphilis
(MOV: HF records)
Also see ACHH I-1 – I-11
25

1 First Level34 (ACFL): Skilled ANC provides for normal pregnancies and manages and/or refers complications.
ACFL S-2. ANC providers link to community net- ACFL I-13. Percent of ANC service sites that have a method for eliciting/seeking community input re: ANC services
works, and works with community, providing infor- (MOV: HFA)
mation about family planning and building capacity
ACFL I-14. Percent of ANC service sites that have met with community committee or key community group/
for activities listed in ACCL S-1.
member(s) during past three months
(MOV: HF records)
ACFL I-15. Percent of ANC service sites that have program/plan to reach community with information about birth
planning, danger signs, and family planning
(MOV: HFA)
Also see ACCL I-1 – I-3.
ACFL S-3. Provide pregnant women with HIV ACFL I-16. Percent health facility staff with knowledge about HIV counseling, testing, prevention, and treatment
counseling and services, using country HIV proto- (MOV: HFA)
col, regarding:
ACFL I-17. Percent pregnant women receiving HIV counseling and testing
• Counseling and testing
(MOV: HF records; ANC client survey or exit interview)
• Transmission of HIV—how virus is spread
• Feeding options45, 46, 47 for HIV-positive ACFL I-18. Percentage of mothers with children age 0–23 months who cite at least two known ways of reducing the
mothers risk of HIV infection*
• Treatment with anti-retroviral drugs, if appro- (MOV: population-based survey)
priate and feasible/country HIV protocol
• How to avoid sexual transmission of HIV
ACFL S-4. Provide pregnant women with informa- See ACHH I-16 – I-20
tion regarding family planning options available so
that children are spaced at least 36 months apart
(PVOs may choose to select 24 months as a bench-
mark)
26

2 Second Level48 (ACSL): Provides comprehensive ANC for pregnancy complications and referrals.
ACSL S-1. Reduce delays in receiving treatment: ACSL I-1. Percent of staff who can demonstrate how to perform a manual vacuum aspiration for bleeding in
• Health workers skilled in providing care for early pregnancy.
pregnant women with signs of a complication (MOV: HFA)
of pregnancy49 ACSL I-2. Percent of staff who can state how to manage bleeding in later pregnancy
• Essential drugs50 for complications during (MOV: HFA)
pregnancy available in facilities
ACSL I-3. Percent of staff who can state how to manage headache/blurred vision/convulsions during pregnancy
• Skilled and informed workers available 24
(MOV: HFA)
hours a day, seven days per week for complica-
tions ACSL I-4. Percent of staff who can state how to manage fever during pregnancy
(MOV: HFA)
ACSL I-5. Percent of women with convulsions during pregnancy who were treated with magnesium sulfate in the
past 12 months
(MOV: HF records)
ACSL I-6. Percent of facilities with uterotonic, magnesium sulfate, RL or NS infusion, ampicillin, gentamycin,
and amoxicillin (or trimeth/sulfamethoxazole) available on day of survey
(MOV: HFA).
ACSL I-7. Percent of health facilities with skilled attendant (doctor, nurse or midwife) available 24 hours per day,
seven days per week
(MOV: HFA)
Key Indicator Definition: Numerator: number of health facilities with skilled attendant (doctor, nurse or midwife)
available 24 hours per day, seven days per week. Denominator: number of health facilities
* Source: derived or taken directly from KPC 2000+; CSTS, CORE

** Source: Flexible Fund Family Planning Guidance; USAID, 2004
*** Source: derived or taken directly from Bertrand J. and Escudero G. Compendium of Indicators
for Evaluating Reproductive Health Programs. MEASURE Evaluation: 2002.
27
Endnotes
1. Focused antenatal care recognizes that every pregnancy is at risk. Antenatal care is not able to
predict all complications, but effective antenatal care balances support for women with normal
pregnancies and early detection and effective management of complications. JHPIEGO. (2004)
“Focused Antenatal Care: Planning and Proving Care During Pregnancy,” Baltimore, U.S.A.
2. Household level is defined as the mother of the baby, her family and helpers providing first aid
in the home or during referral. Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home
Based Life Saving. Guidelines for Decision Makers and Trainers: Protocols. American College of
Nurse-Midwives, Silver Spring, MD, U.S.A.
3. Essential antenatal care: 1. Identify/manage complications, 2. Provide iron/folate, tetanus
toxoid, vitamin A, malaria and parasite prevention and treatment according to country
protocols, 3. Screen and manage HIV/AIDS, tuberculosis, STDs, 4. Discuss preparation for birth
including five cleans, identification of birth attendant, plan for contacting attendant at time of
delivery, transportation plan, family caregivers, ready for emergency with money, transportation,
blood donors, and decision makers, 4. Counsel woman and family on danger signs, nutrition,
family planning, breastfeeding, HIV. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998).
Healthy Mother Healthy Newborn Care. American College of Nurse-Midwives, Washington,
D.C., USA.,
4. See Maternal Nutrition During Pregnancy and Lactation. LINKAGES and The CORE Group’s
Nutrition Working Group; August, 2004; www.linkagesproject.org and www.coregroup.org
“Universal or targeted food fortification can reduce nutritional deficits. In most societies,
women are more likely to be malnourished.” Gay J, Hardee K, et al. What Works: Safe
“Periconceptual intake of 400ug of folic acid daily can reduce the risk of neural tube defects,
including anencephaly, spina bifida, iniencephaly, craniorachischisis, and encephalocele, but not
isolated hydrocephalus . . . Adequate amounts of calcium and magnesium reduce the risk of
eclampsia and prematurity . . . Adequate maternal iodine can halve infant mortality rates and
improve infant health.” Ibid., pp. 81–2.
“Increasing women’s access to microcredit, nutritional information, and technical assistance,
may improve the effectiveness of micronutrient interventions.” Ibid., p. 83.
5. Iron/folate tablets 320 mg (60 mg elemental iron) two times a day, folic acid 500 mcg daily,
and vitamin C daily either 250 mg tablet or advise three daily servings of citrus or leafy green
vegetables; taken during pregnancy and 40 days after baby is born to prevent anemia. Beck,
D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn Care.
American College of Nurse-Midwives, Washington, D.C., USA.
“Treating severe iron-deficiency during pregnancy may reduce the risk of maternal mortality .
. . Treating iron-deficiency anemia with iron during pregnancy has been shown to reduce the
prevalence of anemia and maternal morbidity; in the second trimester, providing iron together
with folate, B-12, riboflavin, and treatment for parasitic infections reduces the risk of maternal
morbidity . . . Training, IEC campaigns, and distribution of iron tablets can reduce anemia.”
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, pp.
78–9.
6. Vitamin A is essential for normal maintenance and functioning of body tissues, for growth
and development, and a strong immune system. Although the increased vitamin A requirement
during pregnancy is small, in countries where vitamin A deficiency is endemic, women need
supplementation. Promoting Quality Maternal and Newborn Care: A Reference Manual for
Chapter 5.

“A 7,000ug retinol equivalent of weekly supplement of vitamin A prior to conception, through
pregnancy and lactation, can reduce maternal mortality and morbidity . . . Daily low dose
vitamin A given during the second and third trimesters of pregnancy substantially reduces
the risk of maternal postpartum infections in women who are deficient in vitamin A.” Gay J,
Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, pp. 82–3.
7. A pregnant woman should be encouraged to increase her intake (of food) and reduce her
workload. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Chapter 5.
8. The most important factors affecting birth outcomes are: 1. Pre-pregnancy weight of the
woman, 2. Pregnancy weight gain, and 3. Workload or energy expenditure. Promoting Quality
Maternal and Newborn Care: A Reference Manual for Program Managers. (1998). Cooperative
for Assistance and Relief Everywhere, Inc (CARE), Chapter 5.
9. “Treating parasitic infections in pregnant women can improve maternal health, reduce maternal
anemia and increase birthweight of infants.” Gay J, Hardee K, et al. What Works: Safe
10. “Preventing, detecting, diagnosing, and treating TB can reduce the numbers of maternal deaths
among pregnant women, including those with HIV.” Ibid., p. 58.
11. “Providers can successfully encourage pregnant women to stop smoking, as well as other family
members who live with the woman . . . Education efforts should encourage pregnant women to
stop smoking, as well as other family members who live with the woman.” Gay J, Hardee K, et
al. What Works: Safe Motherhood. Policy Project, Washington: 2003, pp. 75–6.
12. "Averting exposure to DDT may decrease preterm births and women’s abilities to lactate.” DDT
is widely used against mosquitoes, and is “reasonably anticipated to be a human carcinogen.”
“Decreasing exposure to pesticides may reduce the numbers of spontaneous abortions.” Ibid., p.
60–1.
13. “In areas of moderate to high endemicity: the percent of pregnant women who receive
presumptive antihelminthic treatment during their pregnancy. According to the 1998 IVACG/
WHO/UNICEF Guidelines for the Use of Iron Supplements to Prevent and Treat Iron
Deficiency Anemia, ‘treatment should be done once in the second and third trimester.’ In areas
of low endemicity: the percent of pregnant women who received prescribed treatment during
their pregnancy.” Bertrand J and Escudero G. Compendium of Indicators for Evaluating
Reproductive Health Programs. MEASURE Evaluation: 2002, p. 299.
14. Every woman must know that she may develop a pregnancy-related complication, each time she
becomes pregnant. Promoting Quality Maternal and Newborn Care: A Reference Manual for
Chapter 5. JHPIEGO. (2004) Basic Maternal and Newborn Care: a guide for skilled providers.
Chapter 5. Baltimore, U.S.A.
15. Any bleeding during pregnancy is serious. The bleeding may happen during early pregnancy,
later pregnancy or during labor. Any bleeding during pregnancy is a sign of danger, a sign of
losing the pregnancy, or a sign the woman may die. “Antenatal hemorrhage…between 28-
40 weeks of gestation . . . (may cause a) maternal death . . . within the first 12 hours (of the
bleeding) . . . Intrapartum bleeding is usually due to uterine rupture during obstructed or
prolonged labor and may cause maternal death.” UNICEF/WHO. (1996). Maternal Mortality:
Guidelines for Monitoring Progress. UNICEF. New York.
16. Swelling of hands and face with severe headaches are signs of danger. The pregnant woman
must see a trained health worker as soon as possible. Buffington, S., Sibley, L., Beck, D.,
Armbruster, D. (2004). Home Based Life Saving Skills. Community Meeting 2 and 8. American
College of Nurse-Midwives, Silver Spring, MD, U.S.A. (2004) Basic Maternal and Newborn
Care: a guide for skilled providers. Chapter 5. Baltimore, U.S.A.
Intervention Focus: Antenatal Care 29

Signs and symptoms of severe pre-eclampsia when associated with hypertension, proteinuria,
or edema include (a) hyper-reflexia, (b) headaches, (c) visual disturbances, (d) epigastric pain
(e) oliguria, and (f) increasingly elevated blood pressure and greater proteinuria. Varney, Helen
(1997).Varney’s Midwifery, 3rd edition. Jones and Bartlett Publishers, Sudbury, MA.
17. Fits during pregnancy. Pregnancy fit (eclampsia) is a contributor to maternal mortality. Marshall,
M.A., Buffington, S.T. (1998). Life-Saving Skills Manual for Midwives, 3rd Edition. Module 2.
American College of Nurse-Midwives, Washington, D.C., U.S.A.
18. Lack of fetal movement may be a sign of fetal death or distress. (2004) Basic Maternal and
Newborn Care: a guide for skilled providers. Chapter 5. Baltimore, U.S.A. WHO (2000)
Managing Complications in Pregnancy and Childbirth: a guide for midwives and doctors.
Geneva, Switzerland.
19. Fever may be a sign of infection. (2004) Basic Maternal and Newborn Care: a guide for skilled
providers. Chapter 5. Baltimore, U.S.A. WHO (2000) Managing Complications in Pregnancy
and Childbirth: a guide for midwives and doctors. Geneva, Switzerland.
20. Severe pain in abdomen may be a sign of infection or abruption placenta. Pain when passing
urine may be bladder or kidney infection. JHPIEGO. (2004) Basic Maternal and Newborn
Care: a guide for skilled providers. Chapter 5. Baltimore, U.S.A. Buffington, S., Sibley, L., Beck,
D., Armbruster, D. (2004). Home Based Life Saving Skills. Community Meeting 6. American
College of Nurse-Midwives, Silver Spring, MD, U.S.A.
21. It is essential the decision makers (woman and family) have identified a skilled provider and/or
have items needed for clean birth, have money and transport for care, have support for the
woman and for her family at home. Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004).
Home Based Life Saving Skills. Community Meeting 4. American College of Nurse-Midwives,
Silver Spring, MD, U.S.A. JHPIEGO. (2001) Birth Preparedness and Complication Readiness: a
matrix of shared responsibility. Baltimore, U.S.A.
22. Ibid.
23. Minimum clean birth things at home: 1. Clean surface, 2. Clean cord to tie cord, 3. Clean
blade to cut cord, 4. Clean pads, cloths, and clothes for mother, 5. Clean cloth to wrap baby,
6. Caregivers: Clean hands, apron and gloves. Buffington, S., Sibley, L., Beck, D., Armbruster,
D. (2004). Home Based Life Saving Skills. Community Meeting 3. American College of Nurse-
Midwives, Silver Spring, MD, U.S.A.
WHO refers to the six cleans (A) Clean surface, (B) Clean string to tie the cord, (C) clean blade
to cut the cord, (D) Clean hands of attendant and other helpers, (E) Clean cloths/clothes to wrap
and cover the baby, (F) Clean cloths for mother. World Health Organization. (1999). Care in
Normal Birth: A Practical Guide. WHO/FRH/MSM/96.24. Geneva.
24. Each pregnant woman should receive adequate HIV counseling so she can make an informed
choice regarding ways to prevent HIV and HIV transmission (if HIV-positive) through
breastfeeding. She should fully understand the risk to her child and should receive information
about the risks of HIV transmission through breastfeeding as well as the potential risk of other
infant morbidities if breastfeeding is not selected. World Health Organization, Mother-Baby
Package: Implementing safe motherhood in countries, WHO/FHE/MSM/94.11. Protocols vary
according to country policy and programs.
25. Pregnancy, delivery, and breastfeeding put a considerable strain on a woman’s body. Pregnancies
less than two years apart increase the strain. Severe anemia is common in women with frequent
pregnancies. A woman’s body needs at least 3 years to recover between pregnancies. Arkutu,
A.A. (1995). Healthy Women, Healthy Mothers: An Information Guide, 2nd Edition. Family
Care International, New York.

26. New studies show that longer intervals are even better for infant survival and health, and for
maternal survival and health as well. Children born 3 to 5 years after a previous birth are about
2.5 times more likely to survive than children born before 2 years. Population Reports, Volume
XXX, Number 3, Summer 2002 Series L, Number 13. Issues in World Health.
27. Care During Pregnancy: Health Promotion for Mothers, Partners, and Communities:
• Health education is effective in improving the numbers of women who seek skilled atten-
dance with lower rates of stillbirths and neonatal deaths.
• Women and men desire more information on birth, breastfeeding, family planning, and
couple communication.
• Training providers to involve men in maternity care and provide STI counseling and services
can increase the numbers of men accompanying their wives to ANC clinics ‡.
• Educating male partners and family members concerning safe motherhood improves ANC
attendance.
• Educating male partners concerning safe motherhood improves maternal health outcomes.
• Community education programs as well as individual counseling programs about danger
signals requiring EmOC can increase knowledge and use of EmOC, and are effective in
increasing referrals to EmOC.
• Women, families, and communities should be counseled on the short-term and long-term
positive effects of breastfeeding for the health of infants and the mother, and the need and/or
provision of adequate nutrition for the breastfeeding woman.
‡ “Involvement of male partners, while respecting women’s autonomy for decision making, can
increase needed care during pregnancy and birth. ‘The process of bringing men in needs to be
carefully considered so that in no way are we undermining the often precarious rights of women
to control their own bodies and make their own decisions . . . It must always be kept in mind
that what needs to be protected at all costs is the right of each individual woman not to involve
her partner if she so chooses—without the need of an explanation.’ (Raju S and A Leonard
(eds.) 2000. Men as Supportive Partners in Reproductive Health: Moving from Rhetoric to
Reality. Population Council South and East Asia Regional Office. p. 51)”
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p.
65–74.
28. Information found in Promoting Quality Maternal and Newborn Care: A Reference Manual for
Chapter 5; and Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home Based Life
Saving Skills. Community Meetings 3 and 4. American College of Nurse-Midwives, Silver
Spring, MD, U.S.A.
29. Key elements of birth planning: What to expect during pregnancy; Danger signs of pregnancy,
childbirth, and postpartum; Importance of a skilled provider at birth; Know which health
facility to go to if a complication arises; Know how to get to facility; Develop a plan to pay for
complication services; Importance of immediate and exclusive breastfeeding; Recognize danger
signs for newborns; Importance of family planning and where to get services. Promoting Quality
Maternal and Newborn Care: A Reference Manual for Program Managers. (1998). Cooperative
for Assistance and Relief Everywhere, Inc. (CARE), Chapter 5.
30. Community supports and values use of ANC, recognizes danger signs and implements complication
readiness plan, supports mother- and baby-friendly decision-making, promotes concept of birth
preparedness and complication readiness, has community financing funds, has functional transport
system, has functional blood donor system, conducts dialogue with providers to ensure quality
of care, supports the facility that serves the community. JHPIEGO. “Birth Preparedness and
Complication Readiness: a matrix of shared responsibility. (2001). Baltimore, U.S.A.
Women face several barriers that may delay them from seeking or receiving skilled delivery care
during a life-threatening emergency. These ‘four delays’ are Delay 1) recognizing danger signs;
Delay 2) deciding to seek care; Delay 3) reaching appropriate care; and Delay 4) receiving care
at health facilities. Ransom R, and Yinger N (2002). Making Motherhood Safer: Overcoming
Obstacles on the Pathway to Care. Population Reference Bureau.

31. “Traditional birth attendants (TBAs) and community volunteers can be effective in distributing
iron tablet supplements.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project,
Washington: 2003, p. 64.
See also: Sibley L, Sipe TA, and Koblinsky M, “Does TBA Training Increase Use of Antenatal
Care? A Review of the Evidence” Journal of Midwifery and Women’s Health. (2004) ACNM;
and Sibley L, Sipe TA, and Koblinsky M, “Does TRA Training Improve Referral of Women
with Obstetric Complications: A Review of the Evidence” Social Science and Medicine. (2004)
Elsevier Ltd.
32. Delay 3: Reaching the Health Facility. Once the decision has been made that the mother or the
newborn should seek emergency care, availability and cost of transport are common barriers.
The key to overcoming this problem, especially in isolated communities with few resources, is
community participation. A community that has discussed and recognized underlying reasons
for delays in transportation can often prevent these delays. A specific community plan for
transport emergencies can be helpful, even in remote areas. The Healthy Newborn: A Reference
Manual for Program Managers, CARE, 2001, Part 4, pg. 4.14
33. Buffington, S., Sibley, L., Beck, D., Armbruster, D. Home Based Life Saving Skills, Guidelines
for Decision Makers and Trainers, American College of Nurse-Midwives, Silver Spring,
Maryland, U.S.A., 2004 pg. 32
34. First level is defined as physicians and/or midwives, nurses, paramedical and support
staff providing Basic Emergency Care in health center and during referral. World Health
Organization, Mother-Baby Package: Implementing safe motherhood in countries, WHO/FHE/
MSM/94.11, page 12. Facilities vary according to country.
35. “Routine ANC provided by midwives or general practitioners can have similar outcomes as
when ANC is provided by obstetricians-gynecologists. Midwives can be trained to provide
EmOC. Midwives, particularly with training, can become sources of health information for
pregnant women.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project,
36. Household birth planning includes preparation for birth using the five cleans, locating a birth
attendant and planning for contacting attendant at time of delivery, having a transportation plan
in case of emergency, family caregivers ready to help at home as needed, having some money for
care during emergency and transportation, finding people willing to give blood if this is needed,
and decision makers available during pregnancy. (If decision makers must travel, agreements
should be reached for travel and care in case of an emergency.) Buffington, S., Sibley, L., Beck,
D., Armbruster, D. (2004). Home Based Life Saving Skills. Community Meetings 3 and 4.
American College of Nurse-Midwives, Silver Spring, MD, U.S.A.
37. One complication that may present is pre-eclampsia. “Once identified, there is still no clearly
defined treatment or effective intervention to prevent pre-eclampsia becoming eclampsia.” Gay
J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 59
38. “Sulphadoxine-pyrimethamine is an effective prophylaxis for malaria among pregnant women,
including those who are HIV-positive.” Ibid. p. 55.
39. “Artemisinin drugs can be superior to quinine in preventing death in severe or complicated
malaria, especially for multidrug resistant malaria, but recurrence of malaria after treatment
is frequent . . . Combining artemisinin with other agents, such as mefloquine or lumofantrine,
while expensive, provides effective treatment for malaria and less likelihood of the disease
recurring.” Ibid., p. 56.
40. “Routine counseling and offer of HIV testing should be made to all pregnant women.”
UNAIDS/WHO Policy Statement on HIV testing (June 2004). UNAIDS/WHO.

41. Essential laboratory tests: urine analysis for albumin and diabetes, blood analysis for blood type/
Rh, sickle cell (as appropriate) hemoglobin and hematocrit for anemia (use visual screening where
lab not available), counseling and testing for HIV according to government protocols. Syndromic
screening may be used where tests are not available. Beck D, Buffington S, McDermott J, Berney
K (1998). Healthy Mother Healthy Newborn Care. American College of Nurse-Midwives,
Washington, D.C., USA and World Health Organization, Mother-Baby Package: Implementing
safe motherhood in countries, WHO/FHE/MSM/94.11, pages 27, 29, 30, 31, 33.
42. “Clinical interventions can increase abused women’s safety-seeking behavior… A simple abuse
assessment protocol during ANC can lead to increased detection of abuse and referral.” Gay J,
Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 61–62.
43. “ ‘Gender sensitivity’ is the way service providers treat male or female clients in service delivery
facilities and thus affects client willingness to seek services, continue to use services, and carry
out the health behaviors advocated by the services. This indicator also measures aspects of
the services themselves (e.g. in the case of family planning, whether a range of male as well as
female methods is offered) . . . For a service delivery facility to demonstrate gender-sensitivity, it
must adhere to the principles of informed choice, voluntarism and a target-free approach, which
might otherwise not be the case given the low status of women in the locality. A gender-sensitive
approach has much in common with a quality of care approach. A program cannot be gender-
sensitive if both male and female clients fail to receive complete information and to participate
fully in decisions regarding their care and treatment. Many women want opportunities
to involve their partners in counseling and in decisions concerning contraceptive use and
reproductive and child health. Similarly, many men wish to participate in RH counseling as well
as in decisions regarding reproductive and child health, but have felt excluded from this arena.”
A menu of indicators is provided in Bertrand J and Escudero G. Compendium of Indicators for
Evaluating Reproductive Health Programs. MEASURE Evaluation: 2002, pp. 196–7.
44. “Before HIV testing, health care providers should provide the following minimum information:
HIV is the virus that causes AIDS. HIV is spread through unprotected sexual contact and
injection-drug use. Approximately 25% of HIV-infected pregnant women who are not treated
during pregnancy can transmit HIV to their infants during pregnancy, during labor /delivery, or
through breastfeeding. A woman might be at risk for HIV infection and not know it, even if she
has had only one sex partner. Effective interventions (such as highly active combination anti-
retroviral) for HIV-infected pregnant women can protect their infants from acquiring HIV and
can prolong the survival and improve the health of these mothers and their children. For these
reasons, HIV testing is recommended for all pregnant women. Services are available to help
women reduce their risk for HIV and to provide medical care and other assistance to those who
are infected. Women who decline testing will not be denied care for themselves or their infants.”
CDC Recommends: Prevention Guidelines System. (2001/2002).
Revised Recommendations for HIV Screening of Pregnant Women, MMWR 50(RR19); 59–86,
CDC, Atlanta, GA, USA. http://www.phppo.cdc.gov/cdcRecommends. Protocols vary by
country.
45. HIV and Infant Feeding Counseling Guidelines in Resource-Poor Communities Health Worker
Guidelines
Mother’s HIV status is unknown:
• Promote availability and use of confidential testing
• Promote breastfeeding as safer than artificial feeding ‡
• Teach mother how to avoid exposure to HIV
HIV-negative mother:
• Promote breastfeeding as safest infant feeding method (exclusive breastfeeding for first 6
months, introduction of appropriate complementary foods at about 6 months, and continued
breastfeeding to 24 months and beyond)

HIV-positive mother who is considering her feeding options:
• Treat with anti-retroviral drugs, if feasible
• Counsel mother on the safety, availability, and affordability of feasible infant feeding
options
• Help mother choose and provide safest available infant feeding method
• Teach mother how to avoid sexual transmission of HIV
HIV-positive mother who chooses to breastfeed:
• Promote safer breastfeeding (exclusive breastfeeding up to 6 months, prevention and treat-
ment of breast problems of mothers and thrush in infants, and shortened duration of breast-
feeding when replacements are safe and feasible)
HIV-positive mother who chooses to feed artificially:
• Help mother choose the safest alternative infant feeding strategy (methods, timing, etc.)
• Support her in her choice (provide education on hygienic preparation, health care, family
planning services, etc.)
‡ Where testing is not available and where mothers’ HIV status is not known, widespread use
of artificial feeding would improve child survival only if the prevalence of HIV is high and if the
risk of death due to artificial feeding is low, a combination of conditions that does not generally
exist.
Breastfeeding and HIV/AIDS: Frequently Asked Questions. (April, 2004). LINKAGES Project.
http://www.linkagesproject.org/publications/index.php Protocols vary by country.
46. “During the first two months of life, babies who are not breastfed have a six times greater risk
of dying from infections . . . ” WHO Collaborative Study Team. On the role of breastfeeding on
the prevention of infant mortality. Effect of Breastfeeding on infant and child mortality due to
infectious diseases in less developed countries: A pooled analysis. Lancet 2000; 355: 451–455.
47. “HIV passes via breastfeeding to about 1 out of 7 infants born to HIV-infected women . . . the
lack of breastfeeding is also associated with a three- to five-fold increase in infant mortality.
Infants can die from either the failure to appropriately breastfeed or from the transmission of
HIV through breastfeeding.”
Breastfeeding and HIV/AIDS: Frequently Asked Questions. (2001). LINKAGES Project.
http://www.linkagesproject.org/FAQ_Html/FAQhivrev.htm
48. Second level is defined as physicians, midwives, nurses, paramedical, and support staff providing
Comprehensive Emergency Care (includes operations and blood transfusions) in district hospital
and during referral to tertiary facility. World Health Organization, Mother-Baby Package:
Implementing safe motherhood in countries, WHO/FHE/MSM/94.11, page 12. Facilities vary
according to country.
49. Significant signs of complications of pregnancy include shock, vaginal bleeding, headache/
blurred vision/convulsions, fever, abdominal pain, difficulty breathing, loss of fetal movements,
pre-labor rupture of membranes.
Integrated Management of Pregnancy and Childbirth (IMPAC), Managing Complications
in Pregnancy and Childbirth: A guide for midwives and doctors. (2000), World Health
Organization. WHO/RHR/00.7.
50. Essential drugs for managing complications in pregnancy include: antibiotics, steroids,
emergency drugs, IV fluids, anticonvulsants, antihypertensives, oxytocics, anaesthetics,
analgesics, sedatives, antimalarials, and supplements (tetanus, iron, folic acid, vitamin K).
Integrated Management of Pregnancy and Childbirth (IMPAC), Managing Complications
Organization. WHO/RHR/00.7.

Intervention Focus: Labor and Delivery [LD]
Note: the progression represented by the layout of this list (household, community, first-level, second-level) is ‘best practice’ regarding normal and complicated deliveries. In
other words, standards and illustrative indicators for normal deliveries are listed under ‘household’ and ‘community’; standards and illustrative indicators for complicated
deliveries are included under ‘first-level’ and ‘second-level’.

HH Household Level1 (LDHH): The household prepares for a safe and clean birth, and has an emergency plan.
LDHH S-1. Pregnant women/families/caregiver LDHH I-1. Percent of pregnant women and family who are able to state at least three danger signs of labor
know2 signs of complications during labor and and delivery***
delivery3: (Means of verification [MOV]: population-based survey; client or exit interviews)
1. Heavy bleeding
2. Labor longer than 12 hours LDHH I-2. Percent of caregivers who are able to state at least three danger signs of labor and delivery***
3. Convulsions (MOV: population-based survey; Community-based assessment [community assessment])
4. Pushing more than one hour
5. Malpresentation or head not down or baby’s LDHH I-3. Percent of pregnant women who arrive at the facility due to labor and delivery complications.
head is not coming first5 (MOV: HF records)
6. Fever, chills
7. Membranes ruptured6 for more than 12 hours
before labor
LDHH S-2. Pregnant women and their families have LDHH I-4. Percent of pregnant women and their families who have a birth plan that includes an emergency plan
a birth plan that includes an emergency plan7 (MOV: population-based survey; client or exit interviews)
LDHH S-3. Pregnant women/families/caregivers use LDHH I-5. Percent of pregnant women and their families who are able to list basic clean birth practices
clean birth practices8: (MOV: population-based survey; client or exit interviews)
Pregnant women/families: LDHH I-6. Percent of caregivers who are able to list basic clean birth practices
1. Clean surface (MOV: population-based survey; community assessment)
2. Clean cord to tie cord
3. Clean blade to cut cord LDHH I-7. Percent of recent mothers who report use of clean birth practices during her last delivery
4. Clean pads, cloths, and clothes for mother (MOV: population-based survey; client or exit interviews)
5. Clean cloth to wrap baby LDHH I-8. Percent of caregivers who report use of clean birth practices in every birth during the last 12 months
Caregivers: (MOV: population-based survey; community assessment)
6. Clean hands, apron and gloves
35
HH Household Level1 (LDHH): The household prepares for a safe and clean birth, and has an emergency plan.
LDHH S-4. Pregnant women/their families/caregivers can assist the birth using LDHH I-9. Percent of pregnant women and their families who are able to list basic safe
safe practices: birth practices
1. Allow free position to women during labor and birth, but avoid flat on the (MOV: population-based survey; client or exit interviews)
back
LDHH I-10. Percent of caregivers who are able to list basic safe birth practices
2. Allow the mother to eat and drink as she wants9
(MOV: population-based survey; community assessment)
3. Allow spontaneous pushing
4. Do not use any kind of uterotonic (tea, herbs, drugs10) LDHH I-11. Percent of recent mothers who report use of safe birth practices in her last
5. Make sure that the placenta comes out11 birth
6. Completely dry the newborn, then put the baby skin-to-skin on the abdomen (MOV: population-based survey; client or exit interviews)
of the mother immediately after birth, and cover both12
LDHH I-12. Percent of caregivers who report use of safe birth practices in every birth
during the last 12 months
LDHH S-5. Pregnant women/their families/caregivers know home-based life LDHH I-13. Percent pregnant women and their families who are able to describe emer-
saving skills (HBLSS)13 to provide emergency care in the home14. gency care in the home
1. Identify signs of complications (MOV: population-based survey; client or exit interviews)
a) too much bleeding—call for help, rub womb, stimulate nipples or baby to
LDHH I-14. Percent of caregivers who can demonstrate emergency care in the home
breast, squat and pass urine, external massage and uterine compression,
(MOV: HF records)
apply pressure with cloth/pad to bleeding site, refer15
b) birth delay—squat and pass urine, position changes, fluids, refer16
c) swelling and fits—support to the mother during a convulsion, refer17
d) sickness with pain and fever—position semi-sitting, cover, 1 cup fluids
every hour, sponge bathe, paracetamol 1000mg every 6 hours, pass urine,
when baby has delivered then breastfeed every 2–3 hours, refer18
2. Safe referral (position lying down, warm, fluids, companion go to skilled
provider, tell what happened, what was done)19
LDHH S-6. Skilled providers assist women during birth.

LDHH I-15. Percent of children aged 0-23 months whose delivery was attended by a
skilled health personnel20*
Key Indicator Definition: Numerator: Number of women who delivered with a doc-
tor, nurse midwife, or auxiliary midwife. Denominator: Total number of children aged
0–23 months.
Also see LDHH I-4.
36
Community Level (LDCL): Standards in addition to household level; The community supports families in efforts to ensure safe and clean deliv-
C
eries, and mobilizes around emergency plans.
LDCL S-1. Community is mobilized around an LDCL I-1. Percent of communities with an emergency transport plan in place
emergency finance scheme, emergency transport22 (MOV: HF records; community assessment survey)
scheme, and blood donor pool23, 24, 25 Key Indicator Definition: Numerator: Number of communities that have an emergency transport system;
Denominator: Number of communities
LDCL I-2. Percent of communities that have an emergency financing system
LDCL I-3. Percent of communities that have a blood donor system
LDCL I-4. Percent of communities that have used an emergency transport plan
LDCL S-2. Apply LDHH S-1 to TBAs/CHWs/ LDCL I-5. Percent of TBAs/CHWs/skilled providers who are able to state at least three danger signs of
skilled providers labor and delivery***
(MOV: HF records; TBA survey)
LDCL S-3. Apply LDHH S-5 to TBAs/CHWs/ LDCL I-6. Percent of TBAs/CHWs/skilled providers who can demonstrate HBLSS (MOV: HF
skilled providers. records; TBA survey)
LDCL S-4. TBAs/CHWs/skilled providers are LDCL I-7. Percent of TBAs/CHWs/skilled providers who regularly meet with health facility staff
linked with health facilities to ensure timely/effi- (MOV: HF records)
cient referral of complications.26
37

Community Level (LDCL): Standards in addition to household level; The community supports families in efforts to ensure safe and clean deliv-
C
eries, and mobilizes around emergency plans.
LDCL S-5. Apply LDHH S-3 to TBAs/CHWs/ LDCL I-7. Percent of TBAs/CHWs/skilled providers who regularly meet with health facility staff
skilled providers (MOV: HF records)
LDCL I-8. Percent of TBAs/CHWs/skilled providers who are able to list basic clean birth practices
(MOV: population-based survey; c. assessmt.)
LDCL I-9. Percent of TBAs/CHWs/skilled providers who report use of clean birth practices in every birth during
the last 12 months
See also LDHH I-5 and LDHH I-7.
LDCL S-6. Apply LDHH S-4 to TBAs/CHWs/ LDCL I-10. Percent of TBAs/CHWs/skilled providers who are able to list basic safe birth practices
skilled providers (MOV: population-based survey; community assessment)
LDCL I-11. Percent of TBAs/CHWs/skilled providers who report use of safe birth practices in every birth
during the last 12 months
See also LDHH I-9 and LDHH I-11.
38
First Level 27 (LDFL): Standards in addition to the above levels. Health facilities are staffed with skilled attendants and stocked with essential
1
supplies to ensure safe and clean deliveries. Health facilities work with communities to reduce delays in complication recognition and treatment.
LDFL S-1. Skilled attendants are able to identify and implement basic manage- LDFL I-1. Percent of health providers trained to identify and manage L&D complications
ment of labor and delivery complications according to the WHO guidelines28 (MOV: HF records)
1. Hemorrhage
LDFL I-2. Percent of pregnant women with L&D complications managed according to
2. Prolonged expulsive phase
protocols
3. Obstructed labor
(MOV: HF records)
4. Severe pre-eclampsia and eclampsia
5. Retained placenta/pieces LDFL I-3. Percent of women with obstetrical complications treated within two hours at a
6. Cervical tears health facility***
7. Hypovolemic shock (MOV: HF records; client or exit interview)
8. Sepsis
LDFL S-2. Health providers are able to use best practices to promote the nor- LDFL I-4. Percent of health providers who use best practices to promote normal labor
mal labor process: 29 process
1. Use partograph (MOV: HF records)
2. Encourage walking around (free ambulation)
3. Allow companion husband/family/friends as desired by the woman
4. Encourage the woman in labor to take any position she finds comfortable,
avoiding lying on her back30
5. Use natural ways to manage pain
6. Encourage the woman to drink nourishing fluids or water during labor
7. Encourage a woman in labor to pass urine every two hours
8. Avoid unnecessary interventions (enema, shave, routine IV fluids, excess
vaginal examination, routine episiotomy)
9. Encourage spontaneous pushing
10. Assure privacy, confidentiality/stigma
39
1
LDFL S-3. Health facilities with equipment and supplies available for EOC31 LDFL I-5. Percent of EOC facilities that:
during L&D according to protocols: a) have equipment and supplies; and
1. Use partograph b) use protocols
2. Normal birth (MOV: HFA; HF records)
3. Perform active management of third stage of labor32
4. Perform manual removal of retained placenta/pieces LDFL I-6. Number of facilities per 500,000 population providing essential obstetric
5. Perform assisted vaginal delivery (vacuum extraction or forceps) functions***
6. Administer antibiotics, anticonvulsants, and uterotonics IM or IV and IV (MOV: HFA)
fluids or blood transfusions LDFL I-7. Percent of health providers trained in the practice of active management of
7. Cesarean surgical resolution if needed third stage of labor
(MOV: HF records)
LDFL I-8. Percent of vaginal deliveries documented as having active third stage manage-
ment of labor
(MOV: HF records)
LDFL I-9. Percent of pregnant women with obstetric complications treated in EOC
facilities***
(MOV: HF records)
LDFL S-4. Proactive activities during labor and delivery to prevent maternal-to- LDFL I-10. Percent of health providers trained in PMTCT
child transmission (PMTCT) of HIV during labor and delivery: (MOV: HF records)
1. Avoid rupture of membranes before the birth
LDFL I-11. Percent of HIV-positive women who received appropriate treatment in labor,
2. Avoid vaginal examinations
according to PMTCT recommendations
3. Promote vaginal delivery
(MOV: HF records)
4. Use universal precautions
5. Education on breastfeeding options LDFL I-12. Percent of previously untested women in labor who received appropriate
6. Give anti-retroviral medication (per specific drug and country protocol) counseling and testing for HIV/AIDS
(MOV: HF records)
40
1
LDFL S-5. Health facilities have maternal and neonatal clinical records in place, LDFL I-13. Percent of health facilities that maintain complete maternal records
including labor and delivery information (process, outcome, interventions and (MOV: HFA)
treatment if needed)
LDFL S-6. Health facilities have a referral and answer system functioning LDFL I-14. Percent of health facilities that have a referral and answer system in place
(MOV: HFA)
LDFL I-15. Percent of health facilities that have record of referrals and answer (counter-
referral)
(MOV: HFA)
LDFL I-16. Percent of health facilities that have a method for eliciting/seeking community
input re: labor and delivery services
(MOV: HFA)
LDFL I-17. Percent of health facilities that have met with community committee or key
community group/member(s) during past 3 months
(MOV: HF records)
LDFL I-18. Percent of health facilities that have program/plan to reach community with
information about birth planning, danger signs, and referral
(MOV: HFA)
41

2 Second Level33 (LDSL): Standards in addition to the above levels; Secondary health facilities provide emergency obstetric care.
LDSL S-1. Health facilities with equipment and supplies available for emergency LDSL I-1. Percent of cesarean sections 35**
obstetric care (EmOC34) during L&D according to protocols, which include
Also see LDFL I-6 and I-9.
1. EOC in addition to
2. Surgery
3. Anesthesia
4. Blood replacement
* Source: derived or taken directly from KPC 2000+; CSTS, CORE.

** Source: derived or taken directly from Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy
Project, Washington: 2003
*** Source: derived or taken directly from Bertrand J and Escudero G. Compendium of Indicators for
Evaluating Reproductive Health Programs. MEASURE Evaluation: 2002.
42
Endnotes
Based Life Saving. Guidelines for Decision Makers and Trainers. American College of Nurse-
Midwives, Silver Spring, MD, USA.
2. “Know” refers to the percentage that can spontaneously name at least the primary warning
signs of specific obstetric complications . . . Bertrand, Jane, T. and Gabriela Escudero August
2002, Compendium of Indicators for Evaluating Reproductive Health Programs, MEASURE
Evaluation Series, No. 6, p. 293.
3. Some problems can be prevented if the woman/family understand what actions to do.
Sometimes it is not easy to tell when a problem is going to happen. The labor may be too long
when the baby is not in a head-down position, the baby is too big to come out, something
blocks or stops the baby from coming out, the mother is too weak and tired, the mother has no
strength to push, the womb is too weak and tired, the birth pains are not strong. Buffington, S.,
Sibley, L., Beck, D., Armbruster, D. (2004). Home Based Life Saving. Guidelines for Decision
Makers and Trainers. Community Meetings 3 and 4. American College of Nurse-Midwives,
Silver Spring, MD, USA.
See also: Promoting Quality Maternal and Newborn Care, CARE, 1998, Chapter 5, pg. 5.31
4. “It is not normal to bleed too much after birth. When the bleeding is any amount of continuous
bleeding, or large fist-sized clots, or the woman has weakness and fainting, it is very serious.”
Home Based Life Saving Skills Community Meeting 5, p. 26.
5. If the baby’s head IS down, the birth is more likely to go well. If the baby’s head IS NOT down,
the birth may be difficult. It is safer for the mother and her baby to give birth at a facility with
trained staff. Burns, A.A., Lovich, R., Maxwell, J., Shapiro, K., (1997). Where Women Have
Not Doctor: A Health Guide for Women. The Hesperian Foundation, Berkeley, CA, USA.
6. If at all possible, it is best to go to a referral facility as soon as possible. “. . . rupture of
membranes can increase chances of infection, increase the difficulty of the labor for mother
and baby, and increase risk of mother-to-child transmission of HIV . . . if bag ruptures
spontaneously . . . delivery should occur in less than 4 hours.” Israel, E., and Kroeger, M. 2003.
Integrating Prevention of Mother-to-Child HIV Transmission into Existing Maternal, Child, and
Reproductive Health Programs. Technical Guidance Series. Pathfinder International. Watertown.
7. “. . . planning for childbirth is important because the window of opportunity to treat women
and newborns is short. Reducing the four delays to accessing and receiving services can make
the difference between life and death. It is important to encourage women and their families to
think about the practical aspects of seeking obstetric services prior to an emergency.” Promoting
Quality Maternal and Newborn Care, CARE, 1998, Chapter 5, pg. 5.36
8. Minimum clean birth things at home: 1. Clean surface, 2. Clean cord to tie cord, 3. Clean
blade to cut cord, 4. Clean pads, cloths, and clothes for mother, 5. Clean cloth to wrap baby, 6.
Caregivers: Clean hands, apron and gloves. Buffington, S., Sibley, L., Beck, D., Armbruster, D.
(2004). Home Based Life Saving Skills Community Meetings 3 and 4, and Beck, D., Buffington,
S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn Care. Both are
publications of American College of Nurse-Midwives, Silver Spring, MD USA.
9. “Adequate food and drink during labor is advised to improve fetal outcomes and maternal well-
being.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington:
2003, p. 171.
10. “Uterotonic drugs include: oxytocin, ergometrin, prostaglandin and misoprostol.” Basic
Maternal and Newborn Care: A Guide for Skilled Providers. JHPIEGO (2004). Table 3-3
Uterotonic Drugs, p. 3–106.
Intervention Focus: Labor and Delivery 43

11. “Wait for the placenta to come out. Do not squeeze, push, or press on the womb. Do not pull
on the cord. After placenta comes out, rub the womb, put placenta into waterproof container.”
Home Based Life Saving Skills, Community Meeting 3, p. 57 American College of Nurse-
Midwives, Silver Spring, Maryland, USA. 2004
12. “Mother holds the baby in good sucking position to breastfeed.” Ibid.
13. Home Based Life Saving Skills, Community Meetings 2 and 4, American College of Nurse-
Midwives, Silver Spring, Maryland, USA. 2004
14. The principle of obstetric first aid is to provide immediate measures that can stabilize the
woman and not inflict harm. Table 5.13, page 56 describes current best practices of childbirth.
Table 5.15 describes actions that a family member or a TBA can be trained to perform in the
community to stabilize the woman while mobilizing and carrying out the referral, pg. 5.65. In
case of hemorrhage, reduce or stop bleeding; convulsions, take measures to prevent the woman
from hurting herself before anticonvulsants are administered;, in case of fever or rupture of
membranes, administer antibiotics or antipyretics orally as a temporary measure before being
transferred, pg. 5.63. Promoting Quality Maternal and Newborn Care, CARE, 1998, Chapter 5.
15. Home Based Life Saving Skills, Community Meeting 5, American College of Nurse-Midwives,
Silver Spring, Maryland, USA. 2004
16. Ibid. Meeting 7
17. Ibid. Meeting 8
18. Ibid. Meeting 6
19. MOTHER CARE: Call for help, lay the woman down, cover to keep warm, give liquids to
drink, go directly to the skilled provider at the referral place, tell what happened and what was
done. NEWBORN CARE: Before birth: Help mother/family prepare for birth and in case of an
emergency have money and transportation. At birth: Perform resuscitation, keep warm and go
with family to referral site. Other signs of complications: help mother/family hold baby, keep
baby warm, give baby breast milk, give antibiotics according to country protocols, and go with
family to referral site. Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home Based
Life Saving Skills Community Meeting 4. American College of Nurse-Midwives, Silver Spring,
MD, USA.
20. “A skilled attendant” is a health professional—a midwife, doctor or nurse—who has been
educated and trained to proficiency in the skills needed to manage normal deliveries and
diagnose, manage or refer obstetric complications.” WHO: Fact sheet, Making pregnancy safer.
2/2004
21. Community Level is defined as traditional birth attendants, junior health staff, local leaders,
women’s groups, community workers, traditional healers, other families providing first aid
including specific medications per country protocol in the home, health post, or during referral.
Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home Based Life Saving. Guidelines
for Decision Makers and Trainers. American College of Nurse-Midwives, Silver Spring, MD,
USA.
22. “Successful transportation systems linked to EmOC have decreased the number of maternal
deaths . . . Transportation networks for maternal health can be arranged.” Gay J, Hardee K, et
al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 171.

24. In each setting the communication and transportation needs will vary. However, some common
principles that must be in place to ensure access to obstetric services are: 1) They must be easily
accessible (community must know where to find them), 2) They must be affordable, 3) They
must be safe, 4) They must be reliable, 5) They must be adaptable in order to deal with seasonal
variations, 6) They must be efficient (know which facility to go to and fastest way to get there),
7) They must be culturally appropriate, 8) They must be technologically appropriate so that
they can be properly maintained, 9) They must be endorsed by the community and transport
workers, and 10) They must be available 24 hours a day. Promoting Quality Maternal and
Newborn Care, CARE, 1998, Chapter 5, pg. 5.62
25. “Ensuring adequate blood supplies that have been screened for HIV can avert maternal deaths.”
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p.
171.
26. Improving linkages among the health workers, the community leaders, TBAs, village doctors
and the private sector can encourage health-seeking practices. Promoting Quality Maternal and
27. First level is defined as physicians and/or midwives, nurses, paramedical and support
staff providing Basic Emergency Care in health center and during referral. World Health
Organization, Mother-Baby Package: Implementing safe motherhood in countries, WHO/FHE/
MSM/94.11, page 12. Facilities vary according to country.
28. Managing Complications in Pregnancy and Childbirth: A guide for midwives and doctors,
WHO 2000
29. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn
Care. American College of Nurse-Midwives, Washington, D.C., USA, pgs. 110–111
30. “Allowing women to choose the position in which they want to deliver and increased mobility
for women during labor leads to decreased use of analgesia and reduces time in labor . . . An
upright position during labor increases positive health outcomes for the mother.” Gay J, Hardee
K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 171.
31. “EOC facilities administer parenteral antibiotics, parenteral oxytocic drugs, parenteral
anticonvulsants for pre-eclampsia and eclampsia, and perform manual removal of the placenta,
removal of retained products (e.g. manual vacuum aspiration), and assisted vaginal delivery”
Ibid., p. 165.
32. Active management of the third stage of labor includes: immediate after-birth use of 10 IU
oxytocin IM, controlled cord traction and uterine massage. Managing Complications in
Pregnancy and Childbirth: A guide for midwives and doctors, WHO 2000, C-73
Comprehensive Emergency Care (includes operations and blood transfusions) in district hospital
34. “EmOC includes parenteral (administered by IV) antibiotics; parenteral ocytocic drugs;
parenteral sedatives for eclampsia; manual removal of placenta; manual removal of retained
products plus surgery (including cesarean section); anesthesia; and blood transfusion.” Gay J,
Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 165.
35. Regarding Cesarean Sections, evidence indicates:
• “Access to timely and necessary cesarean sections is critical to reducing maternal mortality.
• Use of prophylactic antibiotics at the time of cesarean sections decreases the incidence of post-
operative infectious morbidity.
• Use of a partogram can decrease rates of cesarean sections.
• In some cases, symphysiotomy can be reasonably performed where cesarean sections are not
available.
Intervention Focus: Labor and Delivery 45

• A subhypnotic dose of 1–2mg/kg per hour of propofol effectively controls the nausea and
vomiting associated with regional anesthesia during cesarean section.
• Vesico-vaginal fistula can be completely averted through timely cesarean section when a
woman has a prolonged labor.”
Ibid., p. 172.

Intervention Focus: Postpartum Care1 [PP]
Note: Best practice in postpartum care considers the mother-baby dyad, recognizing that this is a critical time for both mother and baby. For instructional/educational pur-
poses, these lists maintain separate sections for postpartum and newborn care; however, integrated programming in these areas is strongly recommended. Postpartum mother
and newborn should not be separated.

HH
Household Level (PPHH): The HOUSEHOLD2 prepares for the postpartum period and is ready for complications, including accessing essential
and emergency care, identifying danger signs, and establishing a supportive environment for the postpartum woman.
PPHH S-1. Women/families “know”3 danger signs PPHH I-1. Percent of women/ family members who are able to name three danger signs after delivery***
after delivery (Means of verification [MOV]: population-based survey; ANC client or exit interviews)
1. Heavy bleeding (any amount of continuous
PPHH I-2. Percent of women/families who self refer to health facility for postpartum complications
bleeding, or large fist-sized clots, or the woman
(MOV: HF records)
has weakness and fainting)
2. Loss of consciousness
3. Placenta not delivered within 30 minutes after
delivery
4. Fever with or without chills
5. Foul smelling discharge
6. Convulsions/rigidity
7. Headache, visual disturbances
8. No urine output in first eight hours
9. Severe abdominal pain
PPHH S-2. Mothers/caregivers practice postpartum PPHH I-3. Percent of women/caregivers counseled in postpartum cleanliness/hygiene (MOV: ANC client or exit
cleanliness/hygiene.5 interviews)
PPHH S-3. Infants are immediately breastfed in the PPHH I-4. Percent of women/ families who can state two benefits of exclusive breastfeeding for six months
first hour. Infants are exclusively breastfed for six (MOV: population-based survey; ANC or PPC client or exit interview)
months (no food or drink other than breast milk).6
PPHH I-5. Percent of children aged 0–23 months who were breastfed within the first hour after birth*
PPHH I-6. Percent of infants who were exclusively breastfed in the last 24 hours***
(MOV: population-based survey)7
PPHH I-7. Percent of mothers who can name at least two benefits of initiating breastfeeding within one hour
postpartum
(MOV: population-based survey; client or exit interview)
47

HH
PPHH S-4. Women/families have an emergency PPHH I-8. Percent of women/families with an emergency plan
plan8: (MOV: population-based survey; client or exit interview)
• Know which facility to go to if a
complication arises
• Know how to get to that facility/plan for
transport
• Have money saved or access to a community
fund
PPHH S-5. All postpartum women are counseled PPHH I-9. Percent of women/families who can state at least two benefits of birth spacing
regarding family planning options.9, 10 (MOV: HF records; client or exit interviews)
PPHH I-10. Percent of mothers who use a method of family planning that does not interfere with breastfeeding
(MOV: population-based survey; HF records; client or exit interviews)
PPHH I-11. Percent of postpartum mothers who report initiating use of a modern method of FP within six
weeks after birth**
PPHH I-12. Percent of women who report at least one place where she can obtain a method of family planning*
PPHH I-13. Percent of children aged 0–23 months who were born at least 24 months after the previous surviv-
ing child*
PPHH I-14. Percent of mothers with infants less than six months who report using LAM11**
48

HH
PPHH S-6. Postpartum mothers and newborns PPHH I-15. Percent of women/families who can state two benefits of postpartum care
receive postpartum care12 at appropriate intervals (MOV: population-based survey; HF records; client or exit interviews)
from skilled personnel13:
• Every 15 minutes for one hour and every 30 PPHH I-16. Percent of mothers and newborns who received postpartum care at each recommended inter-
minutes for two hours after delivery ; then at: val from skilled personnel***
• Six hours (MOV: population-based survey; HF records; client or exit interviews)
• One day
• Six days Key Indicator Definition: Numerator: number of women attended at each postpartum interval by skilled
• Six weeks personnel; Denominator: number of live births
• Six months
PPHH S-7. Postpartum mothers take appropriate PPHH I-17. Percent of women/families who can state one benefit of postpartum iron supplementation
micronutrient supplementation: (MOV: population-based survey; client or exit interviews)
• All postpartum women take vitamin A supple-
PPHH I-18. Percent of women/families who can state one benefit of vitamin A for postpartum mother or baby
mentation within six weeks as per recommen-
(MOV: population-based survey; client or exit interviews)
dations.15
• Iron/folate16 PPHH I-19. Percent of anemic postpartum women who took one to two tablets of 60 mg essential iron daily for
three to six months postpartum
(MOV: HF records)
PPHH I-20. Percent of postpartum women who took 200,000 IU vitamin A supplementation within six weeks of
delivery
49

Community Level (PPCL): The community facilitates postpartum preparedness and complication readiness at the household and community
C
levels.
PPCL S-1. Community is mobilized for emergency PPCL I-1. Percent of communities that have an emergency transport system (MOV: HF records; commu-
finance scheme, emergency transport scheme, and nity assessment )
blood donor pool.17 Key Indicator Definition: Numerator: Number of communities that have an emergency transport system;
Denominator: Number of communities
PPCL I-2. Percent of communities that have an emergency financing system

PPCL I-3. Percent of communities that have a blood donor system
PPCL S-2. Community is mobilized (TBAs, CHWs, PPCL I-4. Percent of TBAs/CHWs/community members who can state two benefits of postpartum care
and other community members) for complication (MOV: HF records; community assessment)
readiness and education including:
PPCL I-5. Percent TBAs/CHWs/community members who can name four danger signs for the woman
• Recognize and respond to danger signs in
mother and newborn
• Obstetric first aid care in order to stabilize the PPCL I-6. Number of TBAs/CHWs/community members trained in obstetric first aid
woman or newborn with a complication until (MOV: project or HF records)
reaching trained health worker18
• Encourage postpartum visits PPCL I-7. Percent of women with postpartum complications at home who received obstetric first aid from
• Support consumption of iron and vitamin A trained TBA/community member
supplements (when necessary) (MOV: HF records)
• Support family planning choice PPCL I-8. Percent of trained TBAs/CHWs who can state at least two reasons why breastfeeding should be ini-
• Support chosen infant feeding method19 tiated within one hour postpartum
• PMTCT (in HIV/AIDS-affected areas), specifi- (MOV: HF records; program records; community assessment)
cally infant feeding counseling and breast care
information Also see PPHH I-1 – I-15.
• Linking with health facilities for referral,
advice, and support
See other services in endnotes20,21.
50

First Level (PPFL): Skilled providers give postpartum care to all delivered mothers. Facilities are equipped, staffed, and managed to provide
1
skilled care to the postpartum mother and child.
PPFL S-1. Health workers provide comprehensive PPFL I-1. Percent of health workers trained in postpartum care
postpartum care: (MOV: HFA; HF records)
• Support mother/family
PPFL I-2. Percent of health workers trained to provide postpartum breastfeeding support, counseling, and
• Diagnose and treat complications, including
management of breastfeeding complications
prevention of vertical transmission of diseases
(MOV: HF records)
from mother to infant (e.g. HIV; specifically
infant feeding counseling and breast care) PPFL I-3. Percent of women receiving postpartum breastfeeding counseling and support from health workers
• Refer mother and infant for specialist care (MOV: population-based survey; HF records; client or exit interviews)
when necessary
• Screen and provide counseling and referrals PPFL I-4. Percent of health facilities with no stock-outs of essential supplies in the last quarter27
for GBV and protection from environmental (MOV: HFA)
hazards PPFL I-5. Percent of health facilities with policy of initiating breastfeeding within one hour postpartum
• Encourage use of ITN (where appropriate) (MOV: HFA)
• Counsel on baby care
• Counsel/support breastfeeding PPFL I-6. Percent of health workers who know how to prevent and manage postpartum complications
• Counsel on maternal nutrition and provide (MOV: HFA; HF records)
supplementation (Iron and vitamin A) PPFL I-7. Percent of postpartum complications managed correctly according to protocols
• Counsel and provide contraception (MOV: HF records)
• Counsel on cleanliness and hygiene
PPFL I-8. Percent maternal deaths occurring in postpartum period
(MOV: HF records)
PPFL I-9. Percent of facilities screening for GBV in non-judgmental manner
(MOV: HFA/checklist JHPIEGO/ IPPF)
PPFL I-10. Percent of clients satisfied with services provided
(MOV: client satisfaction survey; client exit interviews)
PPFL I-11. Percent of facilities exhibiting gender sensitivity28 in the service delivery environment***
(MOV: HFA)
Also see PPHH I-5; I-14; I-17; I-18
51

1
PPFL S-2. Emergency equipment and supplies are PPFL I-12. Percent of health facilities with no stock-outs of emergency supplies31 during the previous
available.29 Protocols for management of postpar- quarter
tum emergencies are available30 (MOV: HFA)
PPFL I-13. Percent of facilities with equipment and supplies available for postpartum emergencies
(MOV: HFA)
PPFL I-14. Percent of all women with major obstetric complications who are treated in EOC facilities in a
given reference period***
(MOV: HF records)32
PPFL I-15. Percent of postpartum complications managed correctly according to protocols
(MOV: HF records)
PPFL S-3. Health facilities provide a range of con- PPFL I-16. Number of family planning methods available at nearest service delivery point
traceptive methods.33, 34 (MOV: HFA)
PPFL I-17. Percent of women who, PRIOR to discharge from health facility after birth of baby, receive coun-
seling on family planning and where/how to obtain contraceptive methods
(MOV: population-based survey; HF records; client or exit interview)
PPFL I-18. No stock-outs of family planning methods in the last quarter
(MOV: HFA)
PPFL I-19. Percent of health facilities with both hormonal and non-hormonal methods of family planning
available
(MOV: HFA)
PPFL I-20. Percent of women who are discharged from facility with family planning method
(MOV: population-based survey; HF records; client or exit interview)
52

1
PPFL S-4. All women delivered in health PPFL I-21. Percent of health facilities with policy of monitoring women for at least 24 hours postpartum
facilities are monitored for at least 24 hours (MOV: HFA)
postpartum 35, 36
PPFL I-22. Percent of women delivered in health facilities who are monitored for at least 24 hours
postpartum
(MOV: HF records)
PPFL S-5. Postpartum care providers link to PPFL I-23. Percent of postpartum service sites that have a method for eliciting/seeking community input re:
community networks, and work with community, postpartum services
providing information about family planning and (MOV: HFA)
building capacity for activities listed in PPCL S-2.
PPFL I-24. Percent of postpartum service sites that have met with community committee or key community
group/member(s) during past three months
(MOV: HF records)
PPFL I-25. Percent of postpartum service sites that have program/plan to reach community with information
about postpartum danger signs, breastfeeding support, and family planning
(MOV: HFA)
Also see PPCL I-4 – I-8.
53

2 Second Level (PPSL): Provides comprehensive care for postpartum complications and referrals
PPSL S-1. Reduce delays in receiving treatment: PPSL I-1. Percent of health facilities with skilled attendant (doctor, nurse or midwife) available 24 hours
• Health workers skilled in providing care for per day, seven days per week
pregnant women with signs of a complication (MOV: HFA)
of pregnancy37
Key Indicator Definition: Numerator: number of health facilities with skilled attendant (doctor, nurse or
• Essential drugs38 for complications during
midwife) available 24 hours per day, seven days per week. Denominator: number of health facilities
pregnancy available in facilities
• Skilled and informed workers available
24 hours a day, seven days a week for Also see PPFL I-1 – I-26
complications
Also see PPFL S-1 – S-5

** Source: Flexible Fund Family Planning Guidance; USAID, 2004
*** Source: derived or taken directly from Bertrand J and Escudero G. Compendium of Indicators for
54
Endnotes
1. The ‘postpartum period’ begins after delivery of the placenta and lasts until six weeks after
delivery. Postpartum care includes prevention/early detection and treatment of complications
and disease, and provision of advice/services in breastfeeding, birth spacing, immunization and
maternal nutrition.
Postpartum care includes monitoring:

6–12 hours 3–6 days 6 weeks 6 months
Baby Breathing Feeding Weight Development
Warmth Infection Feeding Weaning
Feeding Routine tests Immunization
Cord
Immunization
Mother Blood loss Breast care Recovery General health
Pain Temperature Anemia Contraception
BP Infection Contraception Continuing
Advice Lochia morbidity
Warning signs Mood
WHO: Postpartum Care of the Mother: A Practical Guide. 1998.
“ Technically, the postpartum period refers only to the first 6 weeks following birth. Returning
the body to a true non-pregnant state takes longer than 6 weeks. This longer duration is
sometimes referred to as the extended postpartum period and may last 6 months or more.”
Varney H, Kriebs J, Gegor C, Varney’s Midwifery, 4th Edition (2004) p.214, Jones & Bartlett.
2. “An important element of routine postpartum care is monitoring of the mother and the
newborn. Most postpartum deaths occur within the first 24 hours . . . Early detection, referral,
and treatment of maternal infection or hemorrhage are essential. Postpartum care includes
the promotion and provision of family planning methods appropriate to lactation, as well as
breastfeeding support as needed. Education about hygiene, rest, nutrition, and infant care will
assist the mother in feeling more secure in tending to her new infant. In settings with maternal
night blindness prevalence > 5% or documented vitamin A deficiency in children, high-dose
VA should be given to mothers within the first eight weeks after delivery (and within six weeks
if the mother is not exclusively or fully breastfeeding). Counseling on continued or initiation
of sleeping under ITNs is important for postpartum women in malaria endemic areas. Daily
maternal iron/folate supplementation should continue in the postpartum period for three
months in areas where anemia prevalence in pregnant women is >40%. In areas with <40%
anemia prevalence in pregnant women, if women have not completed six months of daily
iron/folate supplement consumption during pregnancy, they should continue in the postpartum
period until they have consumed the full amount of 180 tablets.” CSTS+ Technical Reference
Materials: Maternal and Newborn Care. 2004: p.15.
“. . . need to assure early continuing care and monitoring (immediate postpartum period up to
4–6 hours; again 1 day postpartum, and within the first week for mom and second week for
baby….The first several days after birth are important to get at any complications arising from
antenatal and intrapartum concerns and management.” Comments of Donna Vivio, Deputy
Director, Maternal and Neonatal Health, JHPIEGO; 9/28/04
Based Life Saving Skills. Guidelines for Decision Makers and Trainers: Protocols. American
College of Nurse-Midwives, Silver Spring, MD, U.S.A.
Intervention Focus: Postpartum Care 55

3. “Know” refers to the percentage who can spontaneously name at least the primary warning
signs of specific obstetric complications… Bertrand, Jane, T. and Gabriela Escudero August
2002, Compendium of Indicators for Evaluating Reproductive Health Programs, MEASURE
Evaluation Series, No. 6, p. 293.
4. Promoting Quality Maternal and Newborn Care, CARE, 1998, Chapter 5, pg. 5.69
5. “Training women postpartum in pelvic floor exercises can promote urinary continence.” Gay J,
Prevention of Infection. Good hygiene must be promoted if infection is to be minimized.
Regular washing of the hands is important, particularly before caring for the baby. The mother
must be encouraged to keep her perineal area clean, particularly after passing urine or feces.
Antenatal, Perinatal, and Postpartum Care, WHO, 1998, Module 19, pg. 2
6. The Mother-Baby Package (WHO 1994) states that apart from its unquestioned nutritional
superiority, breastfeeding protects against infant death and morbidity. Infants who are
exclusively breastfed are likely to suffer only one quarter as many episodes of diarrhea and
respiratory infections as babies who are not breastfed. Essential Antenatal, Perinatal, and
Postpartum Care, WHO, 1998, Module 20, Infant feeding, pg. 1
7. “Gender Implications of this Indicator: The rate of exclusive breastfeeding, if disaggregated by
sex, can be an indication of whether gender bias exists in the country.” For example, in India,
women more often discontinue breastfeeding girls in the first six months as compared to boys,
contributing to higher malnutrition and death rates for female infants and children. Bertrand
J and Escudero G. Compendium of Indicators for Evaluating Reproductive Health Programs.
MEASURE Evaluation: 2002, p. 361.
8. “. . . planning for childbirth is important because the window of opportunity to treat women
and newborns is short. Reducing the four delays to accessing and receiving services can make
the difference between life and death. It is important to encourage women and their families to
think about the practical aspects of seeking obstetric services prior to an emergency.” Promoting
Quality Maternal and Newborn Care, CARE, 1998, Chapter 5, pg. 5.36
9. New studies show that longer intervals are even better for infant survival and health and for
maternal survival and health as well. Children born 3 to 5 years after a previous birth are about
2.5 times more likely to survive than children born before 2 years. Population Reports, Volume
XXX, Number 3, Summer 2002 Series L, Number 13, Issues in World Health
10. “Postpartum provision of contraception is effective at increasing knowledge of contraception,
desired contraceptive use, potentially increasing the use of ANC, and potentially decreasing
maternal and infant mortality.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy
Project, Washington: 2003, p. 48.
11. LAM (Lactational Amenorrhea Method) is an introductory modern method of family planning
that has three criteria and one parameter: 1) baby is less than six months, 2) baby is fully or
nearly fully breastfeeding, and 3) the mother has not returned to menses. The parameter is that
the mother has readily available a method of FP to use whenever one of the criteria is no longer
true. To realize the fertility impact of LAM, at least 85% of the baby’s nutrition must come
from breast milk. However, exclusive breastfeeding is encouraged until the baby is six months
old. After that, it is recommended to breastfeed the baby first before offering appropriate
weaning foods.
12. “Training midwives to conduct postpartum visits can increase skilled attendance postpartum.”
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 43
13. “Women should be monitored postnatally for at least 24 hours and preferably for one week
following delivery.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project,
14. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn
Care. American College of Nurse-Midwives, Washington, D.C., USA, pgs. 192–198

15. Integrated Management of Pregnancy and Childbirth: Managing Complications in Pregnancy
and Childbirth: A guide for midwives and doctors, WHO 2000, pg. S-26
In settings with maternal night blindness prevalence > 5% or documented vitamin A deficiency
in children, high-dose VA should be given to mothers within the first eight weeks after delivery
(and within six weeks if the mother is not exclusively or fully breastfeeding). CSTS+ Technical
Reference Materials: Maternal and Newborn Care. 2004.
16. “Counseling on continued or initiation of sleeping under ITNs is important for postpartum
women in malaria endemic areas. Daily maternal iron/folate supplementation should continue
in the postpartum period for three months in areas where anemia prevalence in pregnant
women is >40%. In areas with <40% anemia prevalence in pregnant women, if women have
not completed six months of daily iron/folate supplement consumption during pregnancy, they
should continue in the postpartum period until they have consumed the full amount of 180
tablets.” CSTS+ Technical Reference Materials: Maternal and Newborn Care. 2004: p.15.
Also see Maternal Nutrition During Pregnancy and Lactation. LINKAGES and The CORE
Group’s Nutrition Working Group; August, 2004; www.linkagesproject.org and www.
coregroup.org
18. The principle of obstetric first aid is to provide immediate measures that can stabilize the
woman and not inflict harm. Table 5.15 describes actions that a family member or a TBA can
be trained to perform in the community to stabilize the woman while mobilizing and carrying
out the referral. Promoting Quality Maternal and Newborn Care, CARE, 1998, Chapter 5
19. These four behaviors are strongly linked to the prevention of infant malnutrition and illness:
early initiation of breastfeeding (ideally within the first hour after birth), feeding of colostrums
to the newborn, exclusive breastfeeding for the first 0-6 months, continued breastfeeding
through the second year and beyond.
Exclusive breastfeeding for the first six months is a complex behavior involving multiple points
of intervention. Mothers must decide initially to breastfeed and learn the correct techniques.
They need to persevere when difficulties arise, and sometimes they must counter cultural
norms and advice from people they respect regarding supplemental feeding. Information and
counseling throughout this sequence of behaviors can keep mothers on track to exclusive
breastfeeding. Research studies show that various types of interventions can contribute toward
this outcome. Green, Cynthia P., Improving Breastfeeding Behaviors: Evidence from Two
Decades of Intervention Research, AED, The Linkages Project, November 1999, pg. 13
Women who know they are HIV positive should be counseled about the potential risk of
transmission through breast milk; and decide if they want to breastfeed and/or look for
appropriate alternatives if needed. Promoting Quality Maternal and Newborn Care, CARE,
1998, Chapter 5 pg 56.
HIV and Infant Feeding Counseling Guidelines in Resource-Poor Communities Health Worker
Guidelines
Mother’s HIV status is unknown:
• Promote availability and use of confidential testing
• Promote breastfeeding as safer than artificial feeding*

HIV-negative mother:
• Promote breastfeeding as safest infant feeding method (exclusive breastfeeding for first 6
months, introduction of appropriate complementary foods at about 6 months, and continued
breastfeeding to 24 months and beyond)
HIV-positive mother who is considering her feeding options:
• Treat with anti-retroviral drugs, if feasible
• Counsel mother on the safety, availability, and affordability of feasible infant feeding options
• Help mother choose and provide safest available infant feeding method
• Teach mother how to avoid sexual transmission of HIV
HIV-positive mother who chooses to breastfeed:
• Promote safer breastfeeding (exclusive breastfeeding up to 6 months, prevention and treatment of
breast problems of mothers and thrush in infants, and shortened duration of breastfeeding when
replacements are safe and feasible)
HIV-positive mother who chooses to feed artificially:
• Help mother choose the safest alternative infant feeding strategy (methods, timing, etc.)
• Support her in her choice (provide education on hygienic preparation, health care, family
planning services, etc.)
*Where testing is not available and where mothers’ HIV status is not known, widespread use of
artificial feeding would improve child survival only if the prevalence of HIV is high and if the risk
of death due to artificial feeding is low, a combination of conditions that does not generally exist.
Breastfeeding and HIV/AIDS: Frequently Asked Questions. (April, 2004). LINKAGES Project.
http://www.linkagesproject.org/publications/index.php Protocols vary by country.
20. “Traditional birth attendants (TBAs) and community volunteers can be effective in distributing
iron tablet supplements.” Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project,
21. Improving linkages among the health workers, the community leaders, TBAs, village doctors
and the private sector can encourage health-seeking practices. Promoting Quality Maternal and
22. Adapted from JHPIEGO, “Birth Preparedness and Complication Readiness: A Matrix of Shared
Responsibilities” (2001); www.jhpiego.org
23. Postpartum care of the mother and newborn: a practical guide, 1998-WHO/RHT/MSM/98.3,
10.2 Aims and timing of postpartum care
24. “In the event of a stillbirth, both parents benefit from providers allowing parents to choose time
with their dead infant and tokens of remembrance . . . In the event of a diagnosis of intrauterine
death, women benefit from a lapse of no more than 24 hours until induction of labor.” Gay J,
25. “Clinical interventions can increase abused women’s safety-seeking behavior . . . A simple abuse
assessment protocol during ANC can lead to increased detection of abuse and referral.” Gay J,
Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 61–62.
26. Policy Project offers the following evidence-based interventions regarding breastfeeding:
• Successful breastfeeding combined with adequate maternal nutrition, unless a woman is HIV-
positive, is correlated with improved maternal health outcomes.
• Keeping babies with their mothers in the same room (‘rooming in’) or the same bed from
birth (Kangaroo Care Method) prevents infections and increases the success of breastfeeding,
especially when it is combined with breastfeeding guidance.
• On-demand breastfeeding is associated with fewer complications and longer duration of
breastfeeding.

• Ongoing support from nurses for breastfeeding can result in increased duration of exclusive
breastfeeding.
Gay J, Hardee K, et al. What Works: Safe Motherhood. Policy Project, Washington: 2003, p. 45.
27. Including iron and vitamin A supplements
28. “ ‘Gender sensitivity’ is the way service providers treat male or female clients in service delivery
facilities and thus affects client willingness to seek services, continue to use services, and carry
out the health behaviors advocated by the services. This indicator also measures aspects of
the services themselves (e.g. in the case of family planning, whether a range of male as well as
female methods is offered) . . . For a service delivery facility to demonstrate gender sensitivity, it
must adhere to the principles of informed choice, voluntarism and a target-free approach, which
might otherwise not be the case given the low status of women in the locality. A gender-sensitive
approach has much in common with a quality of care approach. A program cannot be gender-
sensitive if both male and female clients fail to receive complete information and to participate
fully in decisions regarding their care and treatment. Many women want opportunities
to involve their partners in counseling and in decisions concerning contraceptive use and
reproductive and child health. Similarly, many men wish to participate in RH counseling as well
as in decisions regarding reproductive and child health, but have felt excluded from this arena.”
A menu of indicators is provided in Bertrand J and Escudero G. Compendium of Indicators for
Evaluating Reproductive Health Programs. MEASURE Evaluation: 2002, pp. 196–7.
29. While there is relatively little evidence on the precise mix of interventions likely to be most
effective in preventing and managing postpartum complications, specific interventions that have
been shown to be effective need to be put in place. These include prophylactic oxytocic drugs
in the third stage of labor to reduce the volume and the incidence of postpartum hemorrhage,
magnesium sulfate for treatment of eclampsia, manual removal of placenta and removal
of retained products of conception, surgical repair of perineal and cervical lacerations, and
prophylactic administration of antibiotics . . . Safe Motherhood Initiatives: Critical Issues, Berer,
M. and Ravindran TK, Editors, Blackwell Science Ltd. for Reproductive Health Matters, 1999.
When Pregnancy Is Over: Preventing Post-Partum Deaths and Morbidity, Carla Abou-Zahr and
Marge Berer, pg. 186
30. Integrated Management of Pregnancy and Childbirth (IMPAC), Managing Complications
Organization. WHO/RHR/00.7.pgs S-25–S-50
31. Oxytocics, Antibiotics, Magnesium sulfate (diazepam), IV fluids
32. Numerator: number of women with major obstetric complication treated in EOC facilities.
Denominator: estimated number of women with obstetric complications from the geographical
area served by the EOC facilities. “The number of pregnant women who develop obstetric
complications requiring medical care to avoid death or disability is estimated to be 15
percent (WHO, 1994a). The number of live births frequently serves as a proxy for all births
or pregnancies; when data on the numbers of live births are absent, evaluators can estimate
them from total expected births = population x crude birth rate.” Bertrand J and Escudero
G. Compendium of Indicators for Evaluating Reproductive Health Programs. MEASURE
Evaluation: 2002, p. 307.
33. For women who are breastfeeding, first choice are methods containing no hormones; second
choice are methods containing only progestin; third choice is a hormonal method containing
both estrogen and progesterone (not advised until baby is six months old because it can reduce
the mother’s milk supply and the long-term effects of the estrogen passing to the baby through
the breast milk are not known). Family planning methods for breastfeeding women include:
first choice-LAM, condoms, spermicide, IUD, sterilization; second choice-progestin-only pill,
injectible progestin, norplant; third choice-combined estrogen/progesterone pill. Healthy Mother
and Healthy Newborn Care, A Reference for Caregivers, ACNM 1998, pg. 229

34. Couples may be unaware of the range of family planning methods (short term, long-acting,
hormonal, barrier, temporary or permanent) available to suit their varying goals, choices and
needs. Such counseling, advice and the provision of services that accompanies it, must form
an integral part of any postpartum service. Postpartum care of the mother and newborn: a
practical guide, WHO/RT/MSM/98.3.
35. The results from an intervention program at a regional hospital in Kigoma, Tanzania, focusing
on improving hospital management to provide a conducive working environment revealed
a reduction in maternal mortality from 933 to 186 per 100,000 live births over the period
1984-1991 (Mbaruku and Bergstrom 1995). The intervention program focused on clarifying
responsibilities, delegating more responsibility to nurses and midwives, regular monthly
meetings with increased feedback, regular staff evaluation, and increased on-the-job training
programs. Other interventions included: regular maintenance of equipment using local materials
and resources, identification of norms for patient management and referral, and development
of a detailed plan for the continuous supply of essential drugs including the initiation of a
sub-store in the maternity ward. Sara Issues Paper, Preventing Maternal Mortality Through
Emergency Obstetric Care, April 1997, May Post, MD DPTM
36. Postpartum Care of the Mother Intervention Package. The overall vision is for every woman
to have routine postpartum care, timely recognition of danger signs, and access to quality
medical care in the event of complications. Aims of key interventions in the postpartum period:
1. Contact with a skilled caregiver: Monitor mothers/newborns for at least the first 24 hours
after delivery. Schedule visits at 6–12 hours, 6 days, and 4–6 weeks, depending on local policy.
Provide support for mother and family, especially breastfeeding. Give vitamin A, 200,000 IU,
for the mother. Provide family planning counseling. Immunize the baby and advise the mother
on newborn care. 2. Reduce delays in access to emergency care: Educate women, households,
and communities about early recognition of danger signs. Provide timely decision-making for
referral. Provide timely transportation. Provide quality care including standard protocols, skilled
staff, sustainable supplies and equipment, and a safe blood supply. The Healthy Newborn: A
Reference Manual for Program Managers, CARE, 2001, Part 4, pg. 4.56
37. Significant signs of complications of pregnancy include shock, vaginal bleeding, headache/
blurred vision/convulsions, fever, abdominal pain, difficulty breathing, loss of fetal movements,
pre-labor rupture of membranes. Integrated Management of Pregnancy and Childbirth
(IMPAC), Managing Complications in Pregnancy and Childbirth: A guide for midwives and
doctors. (2000), World Health Organization. WHO/RHR/00.7.
38. Essential drugs for managing complications in pregnancy include: antibiotics, steroids,
emergency drugs, IV fluids, anticonvulsants, antihypertensives, oxytocics, anaesthetics,
analgesics, sedatives, antimalarials, supplements (tetanus, iron, folic acid, vitamin K). Integrated
Management of Pregnancy and Childbirth (IMPAC), Managing Complications in Pregnancy
and Childbirth: A guide for midwives and doctors. (2000), World Health Organization. WHO/
RHR/00.7.

Intervention Focus: Newborn Care1 [NC]

HH Household Level 2 (NCHH): The household recognizes danger signs, seeks appropriate treatment, and gives essential newborn care.
NCHH S-1. Mother/family members know and can NCHH I-1. Percent of mothers/family members who can state at least three danger signs.**
name newborn danger signs4, 5: (Means of verification [MOV]: population-based survey; client or exit interviews)
• trouble breathing
• poor suck or is not able to suck
• feels hot or cold
• pus or redness any place on the baby: eyes, cord
stump, skin
• fits, rigid, stiff, floppy
• born too small
• poor skin color: pale, blue, yellow
NCHH S-2. Mother /family members practice NCHH I-2. Percent of mothers/family members who can name three essential newborn care practices
essential newborn care:6 (MOV: population-based survey; client or exit interviews)
Warming baby: NCHH I-3. Percent of children aged 0-23 months who were immediately breastfed at birth*
• Drying7 and8 (MOV: population-based survey)
• Wrap baby, including head
• Skin to skin contact to maintain warmth Key Indicator Definition: Numerator: Number of children breastfed within the first hour after birth;
• Delay bathing for 24 hours9 Denominator: Number of children aged 0–23 months
Clean cord care: NCHH I-4. Percent of children aged 0–23 months who were placed with the mother immediately after birth*
• Secure cord tie with clean ties (MOV: population-based survey; HF or TBA/CHW records)
• Clean cord cut
• Keep cord dry NCHH I-5. Percent of children aged 0–23 months whose delivery involved use of a clean birth kit or whose
• Put nothing on it cord was cut with a new razor*
(MOV: population-based survey; HF or TBA/CHW records)
Initiating immediate breastfeeding10
Key Indicator Definition: Numerator: Number of children aged 0–23 months whose delivery involved use of a
Kangaroo care for low birth-weight (LBW)
clean birth kit or whose cord was cut with a new razor; Denominator: Number of children aged 0–23 months
babies11
NCHH I-6. Percent of newborns with delayed bathing
61

HH Household Level 2 (NCHH): The household recognizes danger signs, seeks appropriate treatment, and gives essential newborn care.
NCHH S-3. Newborns receive a check-up visit12

NCHH I-7. Percent of newborns who receive postnatal care from a skilled provider at each recommended
with skilled health worker, which should coincide
interval**
with postpartum visits and care:13, 14
• Every 30 minutes during the first two hours
after delivery; then at:
• six hours Key Indicator Definition: Numerator: Number of newborns who receive postnatal care from a skilled pro-
• one day vider at each recommended interval; Denominator: Number of live births
• six days
• six weeks NCHH I-8. Percent of recently delivered women who had a postpartum visit within 6 days
• six months (MOV: HF, TBA/CWH records; client interview)
(Note: this is a community-based indicator assum- NCHH I-9. Percent newborns referred for sepsis
ing a health worker comes to visit.) (MOV: HF records)
NCHH I-10. Percent of children aged 0–23 months who have a vaccination card*
Immunizations BCG, OPV, Hepatitis B according
to country protocol; monitor for danger signs as
listed above. NCHH I-11. Percent of children aged 12–23 months who received measles vaccine*
Purpose of visits15:
• Check for danger signs NCHH I-12. Percent of children aged 12–23 months who received BCG, DPT3, OPV3, and measles vac-
• Encourage immunizations cines before the first birthday*
• Counsel mothers on newborn care (MOV: population-based survey)
• Counsel mothers on breastfeeding
• Check to see if mothers have had postpartum NCHH I-13. Percent of infants aged 0–5 months who were fed breast milk only in the last 24 hours*
vitamin A (MOV: population-based survey)
• Counsel on sleeping under an ITN (in malarial NCHH I-14. Percentage of children aged 0–23 months who slept under an insecticide-treated bednet the
countries) previous night*
Also see NCHH I-1 and I-2.
62

C Community Level (NCCL): The community supports postnatal16 visits with a skilled provider and essential newborn care17
NCCL S-1. TBAs/CHWs:

NCCL I-1. Percent of TBAs/CHWs who can name 3 essential newborn care practices
• Recognize and respond to danger signs18 in
newborn19
• Provide first aid care20 in order to stabilize NCCL I-2. Percent of TBAs/CHWs who can demonstrate first aid care for at least three newborn danger
the newborn with a complication until reach- signs
ing a skilled health worker (MOV: HF records; community assessment)
• See NCHH S-1.
NCCL I-3. Percent of TBAs/CHWs who can state four newborn danger signs**
See also NCHH I-3 – I-5.
63

First Level 21 (NCFL): The health facility has trained staff, equipment, and supplies to provide essential newborn care, shows mothers how to
1 care for newborns, and recognizes and treats complications. The health facility also links with the community to promote essential newborn
care and recognition of danger signs.
NCFL S-1. Maternity facilities are “Baby- NCFL I-1. Percent of facilities that are designated “Baby Friendly”**
Friendly”22: (MOV: HFA)
1. Written breastfeeding policy for all health care NCFL I-2. Percent of facilities with a delivery room adequately equipped for newborn care
staff (MOV: HFA)
2. Train all health care staff in skills necessary to
implement policy NCFL I-3. Percent of pregnant women informed about breastfeeding benefits
3. Inform all pregnant women about breastfeed- (MOV: population-based survey; client or exit interview)
ing and LAM NCFL I-4. Percent of delivered women shown how to breastfeed
4. Help mothers initiate breastfeeding within an (MOV: population-based survey; client or exit interview)
hour of birth
5. Show mothers how to breastfeed and how to NCFL I-5. Percent of women shown how to maintain lactation
maintain lactation23 (MOV: population-based survey; client or exit interview)
6. Give newborn infants no food or drink other
NCFL I-6. Percent of women who report that they were helped to initiate breastfeeding
than breast milk
(MOV: population-based survey; client or exit interview)
7. Practice “rooming in” 24 hours a day
8. Kangaroo care for low birth-weight (LBW) NCFL I-7. Percent of newborns who had kangaroo care
babies
9. Encourage breastfeeding on demand Also see NCHH I-3, I-4, and I-10.
10. Give no artificial teats, or pacifiers to breast-
feeding infants
11. Foster breastfeeding support groups and refer
mothers to them
64

NCFL S-2. Skilled health workers24 provide essen- NCFL I-8. Percent of staff skilled in management of birth asphyxia
tial components of normal newborn care25, 26: (MOV: HFA)
1. Clean delivery and cord care, NCFL I-9. Percent of staff skilled in eye care and immunization
2. Thermal protection to prevent newborn hypo/ (MOV: HFA)
hyperthermia,
3. Early (started within 1 hour of birth) and NCFL I-10. Percent of staff skilled in sepsis management
exclusive breastfeeding, unless HIV+ mother (MOV: HFA)
has decided otherwise NCFL I-11. Percent of staff skilled in low birth-weight management
4. Identification and management of birth (MOV: HFA)
asphyxia (including initiation of breathing
and resuscitation), sepsis27, 28 and low birth NCFL I-12. Percent of sepsis treatment and resuscitation managed according to protocols
weight29 (MOV: HF records)
5. Eye care to prevent and manage ophthalmia
NCFL I-13. Percent of newborns monitored for at least 24 hours
neonatorum
(MOV: HF, TBA/CHW records)
6. HIV antiretroviral given to HIV+ mother
(according to drug and country protocol) Also see NCFL I-3 and I-6.
7. Immunizations BCG, OPV, Hepatitis B accord-
ing to country protocol, monitor for danger
signs as listed above
8. Monitor newborn for at least 24 hours
65

NCFL S-3. Provide to all delivered women using NCFL I-14. Percent of staff trained in HIV35:
country HIV protocol30: • Prevention
1. Counseling and testing31 • Counseling and testing
2. Information on how to avoid sexual • Treatment
transmission of HIV (MOV: HF records)
Provide HIV information32 to HIV-positive deliv- NCFL I-15. Percent of delivered women receiving HIV PMTCT and prevention information
ered women using country HIV protocol: (MOV: population-based survey; HF records; client or exit interview)
1. Feeding options33 of safety, availability,34 NCFL I-16. Percent of HIV-positive delivered women receiving PMTCT (ART, BF and prevention counsel-
and affordability, ing, etc.) and prevention information
2. Treat with anti-retroviral drugs, if appropriate (MOV: HF records)
and feasible/country HIV protocol
3. Teach how to avoid sexual transmission of
HIV
NCFL S-4. Newborn care providers link to com- NCFL I-17. Percent of health facilities that have met with community committee or key community group/
munity networks, and work with community to member(s) during past three months
build capacity to recognize newborn danger signs, (MOV: HF records)
give first aid, and refer to a health facility.
NCFL I-18. Percent of health facilities that have program/plan to reach community with information about
newborn danger signs and breastfeeding support
(MOV: HFA)
66

2 Second Level (NCSL): Second level care facilities provide essential newborn care and manage newborn complications.
NCSL S-1. See NCFL S-1. See NCFL I-1 – I- 7.

Also see NCHH I-3, I-4, and I-10.
NCSL S-2. See NCFL S-2. See NCFL I-8 – I-13.

Also see NCFL I-3 and I-6.
NCSL S-3. See NCFL S-3. See NCFL I-14 – I-16.
NCSL S-4. Newborn care providers link to first- NCSL I-1. Percent of second-level health facilities that have program/plan to reach first-level health facilities
level referral facilities to build capacity to recog- with information about newborn danger signs, first aid, appropriate referral to higher level
nize newborn danger signs, give first aid, and refer (MOV: MOH)
to second level health facility appropriately
NCSL S-5. Infants of HIV-positive mothers receive NCSL I-2. Percent of newborns of HIV-positive mothers who receive anti-retrovirals per country protocol
antiretrovirals per country protocol (MOV: HR records)

** Source: derived or taken directly from Bertrand J and Escudero G. Compendium of Indicators for
67
Endnotes
1. Newborn refers to a baby between birth and one month of age. MAQ Exchange: Reproductive
Health and HIV Presentations.
Based Life Saving: Guidelines for Decision Makers and Trainers. American College of Nurse-
Midwives, Silver Spring, MD USA.
3. “Know” refers to the percentage who can spontaneously name the warning/danger signs of
newborn complications. Bertrand, Jane, T. and Gabriela Escudero August 2002, Compendium
of Indicators for Evaluating Reproductive Health Programs, MEASURE Evaluation Series,
Volume Two, Indicators for Specific Programmatic Areas, p. 318.
4. Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice. World
Health Organization, 2003, p. J7.
5. Home Based Life Saving Skills. Community Meeting 2. American College of Nurse-Midwives,
Washington, D.C. USA.
6. Essential newborn care practices for home birth: 1. Breathing observation: person skilled in
mouth suction for newborn resuscitation and newborn problem identification. 2. Warmth: dry
baby and place skin to skin with mother, clean cloths to keep warm, delay bathing of baby
for at least 24 hours, 3. Cord care: clamping/tying, cutting, air dry. 4. Prophylactic eye care:
wipe with clean and dry cloth, antibiotic drops per local protocol. 5. Immediate breastfeeding.
Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home Based Life Saving Community
Meeting 3. American College of Nurse-Midwives, Silver Spring, MD USA. and Promoting
Quality Maternal and Newborn Care: A Reference Manual for Program Managers. (1998).
Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Chapter 5.
7. Blood on newborn is not a risk to newborn, but is a risk to caregiver. MAQ Exchange:
Reproductive Health and HIV Presentations
8. Do not separate mother and newborn. Leave newborn skin-to-skin with mother. In areas
with high HIV prevalence, consider bathing newborn earlier to reduce risk of maternal-fetal
transmission, and to reduce risk to caregiver. MAQ Exchange: Reproductive Health and HIV
Presentations.
9. Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2004). Home Based Life Saving Basic
Information. American College of Nurse-Midwives, Silver Spring, MD USA, p.72.
10. “During the first two months of life, babies who are not breastfed have a six times greater risk
of dying from infections . . . ” WHO Collaborative Study Team. On the role of breastfeeding on
the prevention of infant mortality. Effect of Breastfeeding on infant and child mortality due to
infectious diseases in less developed countries: A pooled analysis. Lancet. 2000; 355: 451–455.
11. Low birth-weight care includes: Adequate breast milk and warmth can substantially reduce
mortality (CARE), keep baby warm and dry and with mother, breastfeed frequently; if the
baby can not suck—express breast milk and use a cup to feed the baby. It takes a devoted
mother/family and staff to help this baby survive. Staff go with mother/family to second level
referral site. Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Chapter
5 and Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy
Newborn Care. American College of Nurse-Midwives, Washington, D.C. USA.

12. “The first days and weeks in a baby’s life are critical. Two thirds of infant deaths occur within
the first four weeks after birth, and more than 65% of these die within the first 7 days after
birth. Close monitoring and care of a mother and baby and teaching in the postpartum period
by a trained health worker may prevent some of these deaths.” Beck, D., Buffington, S.,
McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn Care. American College
of Nurse-Midwives, Washington, D.C. USA, p. 181.
13. Frequency of postnatal visits (10.4.3) for the newborn. “. . . with limited resources, a contact
with the health care system at least during the first twenty-four hours and before the end of
the first week would be most effective.” (10.5) The first months. “At the age of 6 weeks the
baby receives a second dose of OPV and first dose of DPT vaccine. Baby’s growth should be
assessed.” Postpartum Care of the Mother and Newborn: WHO/RHT/MSM/98.3, page 55–56.
14. Clean delivery and cord care (prevent infection), Thermal protection (baby sleeps with mother,
bathing after 24 hours), Early asphyxia identification and management, Help mothers initiate
breastfeeding within one hour of birth and sustain exclusive and demand breastfeeding, Monitor
baby for 24 hours, Followup visits at end of first week after birth and 6 weeks (Postpartum
Care of the Mother and Newborn: WHO/RHT/MSM/98.3, page 55–56.), Prevent and manage
ophthalmia neonatorum, Provide immunizations, Identification and management of sick,
preterm, and/or low birth weight newborn including. Beck, D., Buffington, S., McDermott,
J., Berney, K. (1998). Healthy Mother Healthy Newborn Care. American College of Nurse-
Midwives, Washington, D.C. USA., p.181–246.
15. Whenever possible this should happen together with the mother’s postpartum visit. The first
visit can occur anytime before the mother is discharged from the facility (but within the first
24 hours). The aim is that with early recognition and management/treatment of problems,
reinforcement of danger signs and complication readiness, and opportunities for health
education and counseling to the mother and family, that some of the maternal and neonatal
deaths could be averted.
16. ‘Postpartum visit’ varies by country, whether referring to the mother, baby, or both. This list
refers to ‘postnatal’ visits because the focus of the list is newborn care; these are the same as
postpartum visits.
The ‘postnatal’ period begins one hour after the birth of the placenta and ends 6 weeks
later. Bertrand, Jane, T. and Gabriela Escudero August 2002, Compendium of Indicators
for Evaluating Reproductive Health Programs, MEASURE Evaluation Series, Volume Two,
Indicators for Specific Programmatic Areas, p. 323.
17. Post delivery newborn care: Observe/feel: skin temperature, skin color, ability to breastfeed,
activity, stools, eyes and cord for redness and/or discharge. If country protocol includes
weighing the baby, this is done. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998).
Healthy Mother Healthy Newborn Care. American College of Nurse-Midwives, Washington,
D.C. USA.
18. At birth: baby not breathing, skin color yellow, trouble breathing (labored), fits; and first seven
days: hypothermia/fever, poor skin color, poor or not sucking, not active, diarrhea, discharge
and redness in eyes or around the cord. Buffington, S., Sibley, L., Beck, D., Armbruster, D.
(2004). Home Based Life Saving Community Meeting 2. American College of Nurse-Midwives,
Silver Spring, MD USA and Promoting Quality Maternal and Newborn Care: A Reference
Manual for Program Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc.
(CARE), Chapter 5.
Intervention Focus: Newborn Care 69

WHO lists danger signs as: fast breathing (more than 60 breaths per minute); slow breathing
(less than 30 breaths per minute); severe chest in-drawing; grunting; convulsions; floppy or
stiff;fever or feels hot; hypothermia or feels cold; discharge from cord, redness around cord
stump, foul odor; more than 10 skin pustules or bullae (or swelling, redness, hardness of skin);
bleeding from cord or stump; repeated vomiting; no stool by 24 hours of age; skin color pale or
blue; skin color and eye color yellow from jaundice (1st three days); feeding poorly; born too
small and discharge from eyes. “Pregnancy, Childbirth, Postpartum and Newborn Care: A guide
for essential practice” WHO (2003). P. J7
19. Newborn danger signs: breathing difficulty, convulsions or spasms, blueness or pallor, hot or
cold to touch, yellowness, diarrhea, persistent vomiting, not feeding or poor suckling, floppiness
or lethargy, pus or redness of umbilicus or eyes or skin. JHPIEGO (2004) Basic Maternal and
Newborn Care: a guide for skilled providers. Chapter 8. Baltimore, U.S.A.
20. Newborn care: Before birth: Help mother/family prepare for birth and in case of an emergency,
have money and transportation. At birth: Perform resuscitation, keep warm and go with family
to referral site. If other signs of complications: help mother/family hold baby, keep baby warm,
give baby breast milk, give antibiotics according to country protocols, and go with family to
referral site. Buffington, S., Sibley, L., Beck, D., Armbruster, D. (2003). Home Based Life Saving
Skills. Community Meeting 3 and 4. American College of Nurse-Midwives, Washington, D.C.
USA. and Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. (1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Chapter 5.
21. First level is defined as physicians and/or midwives, nurses, paramedical and support staff
providing basic emergency care in health center and during referral. World Health Organization,
Mother-Baby Package: Implementing safe motherhood in countries, WHO/FHE/MSM/94.11,
page 12. Facilities vary according to country.
22. Baby-Friendly according to the ten UNICEF/WHO criteria related to breastfeeding and newborn
care: 1. Written breastfeeding policy routinely communicated to all health care staff; 2. Train
all health care staff in skills necessary to implement policy; 3. Inform all pregnant women
about the benefits and management of breastfeeding; 4. Help mothers initiate breastfeeding
within an hour of birth; 5. Show mothers how to breastfeed and how to maintain lactation,
even if they should be separated from their infants; 6. Give newborn infants no food or drink
other than breast milk, unless medically indicated; 7. Practice ‘rooming in’ by allowing mothers
and infants to remain together 24 hours a day; 8. Encourage breastfeeding on demand; 9.
Give no artificial teats, pacifiers, dummies, or soothers to breastfeeding infants; 10. Foster the
establishment of breastfeeding support groups and refer mothers to them on discharge from the
hospital or birthing center. World Health Organization, Mother-Baby Package: Implementing
safe motherhood in countries, WHO/FHE/MSM/94.11. and Bertrand, Jane, T. and Gabriela
Escudero August 2002, Compendium of Indicators for Evaluating Reproductive Health
Programs, MEASURE Evaluation Series, Volume Two, Indicators for Specific Programmatic
Areas, p. 317. Protocols vary according to country policy and programs.
23. Includes 24-hour ‘rooming in,’ feeding on demand, no artificial teats or pacifiers.
24. When things go well, the skilled attendant avoids complications through clean and safe delivery,
as well as providing the link to other services such as family planning and treatment of sexually
transmitted infections.
25. Clean delivery and cord care to prevent newborn infection, thermal protection to prevent
and manage newborn hypo/hyperthermia, early (started within 1 hour of birth) and exclusive
breastfeeding, identification and management of birth asphyxia including initiation of breathing
and resuscitation, monitoring for at least 24 hours, eye care to prevent and manage ophthalmia
neonatorum, immunization at birth with BCG, oral poliovirus vaccine (OPV) and hepatitis B
vaccine (HBV) according to country protocols. MAQ Exchange: Reproductive Health and HIV
Presentations; and World Health Organization 1999. Care in Normal Birth: A Practical Guide.
WHO/FRH/MSM/96.24 Geneva.

26. Minimum preparation for any birth: The following should be available and in working order:
one clock with second hand, at least one person skilled in newborn resuscitation present at the
birth, heat source, mucus extractor, self-inflating bag of newborn size with normal and small-
size masks (alternative devices in place of self-inflating bag are now being developed that are
safe and effective. Milner, A. et al. 1990. A device for domiciliary neonate resuscitation. Lancet
335:273–275.), MAQ Exchange: Reproductive Health and HIV Presentations.
27. Sepsis in newborn: Hypothermia, fever/chills, unable to suck breast, breathe faster then 60
breaths per minute. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother
Healthy Newborn Care. American College of Nurse-Midwives, Silver Spring, MD USA.
28. Case fatality rate for severe bacterial infections such as pneumonia is high and it is important
to quickly begin treatment and refer the infant. Antibiotics are essential as soon as possible.
Treatment protocols vary according to country, however consideration should be made to
prevent hypoglycemia with continued breast milk and intravenous fluids when baby unable
to take sufficient breast milk, antibiotics. Go with mother/family to second level referral site.
Promoting Quality Maternal and Newborn Care: A Reference Manual for Program Managers.
(1998). Cooperative for Assistance and Relief Everywhere, Inc. (CARE), Chapter 5.
29. Low birth weight: Babies that are small at birth or weigh less than 2,500 grams need extra care.
Their lack of fat stores as a source of energy and insulation make them at risk for hypothermia
and poor growth. Promoting Quality Maternal and Newborn Care: A Reference Manual for
Chapter 5.
30. The first visit within 24 hours using country HIV protocol should include 1. A report from
mother/family—How is the baby doing including breastfeeding; 2. Were there any problems
at birth or immediately afterward; 3. Examine baby in a clean place where mother/others can
watch: general appearance, breathing, temperature, weight, eyes, mouth, reflexes, skin, cord;
4. Counsel: reminder of danger signs for baby, cord care, eye care and delay bathing; 5. HIV
prevention and treatment. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy
Mother Healthy Newborn Care. American College of Nurse-Midwives, Washington, D.C. USA.,
p.198–207 and Anderson, J.R., (2001). Care of Women with HIV Living in Limited-Resource
Settings—HIV and Breastfeeding. MAQ Exchange: Reproductive Health and HIV Presentations.
The second visit by the end of the first week after birth using country HIV protocol should
include 1. Report from mother/family about how baby is doing and breastfeeding practice;
2. Examination of the baby in a clean place where the mother/others can watch: general
appearance, breathing, temperature, weight, eyes, mouth, reflexes, skin cord; 3. Counsel:
Danger signs, breastfeeding, hygiene, cord care, immunizations (BCG, OPV, Hepatitis
B according to country protocol), jaundice; 4. HIV prevention and treatment. Beck, D.,
Buffington, S., McDermott, J., Berney, K. (1998). Healthy Mother Healthy Newborn Care.
American College of Nurse-Midwives, Washington, D.C. USA., p 219–221 and Anderson, J.R.,
(2001). Care of Women with HIV Living in Limited-Resource Settings—HIV and Breastfeeding.
MAQ Exchange: Reproductive Health and HIV Presentations.
Six weeks after birth, the exam is similar to the initial exam using country HIV protocol plus
observing the baby breastfeeding. 1.Ask about breastfeeding, sleep, stool, immunizations; 2.
General examination and growth monitoring; 3. Give immunizations if needed; 4. Counsel on
breastfeeding, immunizations, growth monitoring, danger signs and family planning; 5. HIV
prevention and treatment. Beck, D., Buffington, S., McDermott, J., Berney, K. (1998). Healthy
Mother Healthy Newborn Care. American College of Nurse-Midwives, Washington, D.C. USA.,
p. 238–240 and Anderson, J.R., (2001). Care of Women with HIV Living in Limited-Resource
Settings—HIV and Breastfeeding. MAQ Exchange: Reproductive Health and HIV Presentations.
Intervention Focus: Newborn Care 71

31. Each HIV-positive mother should receive adequate counseling so she can make an informed
choice regarding ways to prevent transmission through breastfeeding. She should fully
understand the risk to her child and should receive information about the risks of HIV
transmission through breastfeeding as well as the potential risk of other infant morbidities if
breastfeeding is not selected. World Health Organization, Mother-Baby Package: Implementing
safe motherhood in countries, WHO/FHE/MSM/94.11. Protocols vary according to country
policy and programs.
32. “Before HIV testing, health care providers should provide the following minimum information:
HIV is the virus that causes AIDS. HIV is spread through unprotected sexual contact and
injection-drug use. Approximately 25% of HIV-infected pregnant women who are not treated
during pregnancy can transmit HIV to their infants during pregnancy, during labor/delivery, or
through breastfeeding. A woman might be at risk for HIV infection and not know it, even if she
has had only one sex partner. Effective interventions (such as highly active combination anti-
retrovirals) for HIV-infected pregnant women can protect their infants from acquiring HIV and
can prolong the survival and improve the health of these mothers and their children. For these
reasons, HIV testing is recommended for all pregnant women. Services are available to help
women reduce their risk for HIV and to provide medical care and other assistance to those who
are infected. Women who decline testing will not be denied care for themselves or their infants.”
CDC Recommends: Prevention Guidelines System. (2001/2002). Revised Recommendations for
HIV Screening of Pregnant Women, MMWR 50(RR19); 59-86, CDC, Atlanta, GA, USA.
http://www.phppo.cdc.gov/cdcRecommends
33. “Mother’s HIV status unknown—promote breastfeeding as safer than artificial feeding where
HIV testing not available and risk of infant death due to artificial feeding is high. Mother HIV-
negative—promote breastfeeding as safest infant feeding method. Mother HIV-positive who
chooses to breastfeed—promote safer breastfeeding: exclusive breastfeeding up to six months,
prevent and treat any breast problems of mothers and thrush in infants, shorten duration of
breastfeeding when replacements are safe and feasible. Mother HIV-positive who chooses
to feed artificially—help mother and family choose safest alternative infant feeding, support
mother/family with education on hygienic preparation, health care, family planning services,
etc.” Feeding options from Breastfeeding and HIV/AIDS: Frequently Asked Questions. (2001).
LINKAGES Project. http://www.linkagesproject.org/FAQ_Html/FAQhivrev.htm
34. “HIV passes via breastfeeding to about 1 out of 7 infants born to HIV-infected women . . . the
lack of breastfeeding is also associated with a three- to five-fold increase in infant mortality.
Infants can die from either the failure to appropriately breastfeed or from the transmission
of HIV through breastfeeding.” Breastfeeding and HIV/AIDS: Frequently Asked Questions.
(2001). LINKAGES Project. http://www.linkagesproject.org/FAQ_Html/FAQhivrev.htm
35. See WHO/CDC PMTCT Training Package (2004). www.womenchildrenhiv.org
comprehensive emergency care (includes operations and blood transfusions) in district hospital

Appendix I
Key Indicators
Pre-conception/Inter-conception:
PCHH I-1. Percent of boys and girls age 0–23 months who are underweight (–2 SD from the
median weight-for-age, according to the WHO/NCHS reference population)*
Key Indicator Definition: Numerator: Number of children age 0–23 months whose weight
is –2 SD from the median weight of the WHO/NCHS reference population for their age;
Denominator: Number of children age 0–23 months in the survey who were weighed (If
there is reason to believe that girls are fed differently than boys, then compute a ratio of
malnutrition [girls to boys] using the data collected)
PCHH I-16. Percent of WRA who have completed at least four years of schooling**
Key Indicator Definition: Numerator: #of women ages 15–49 who completed four years of
schooling; Denominator: Total # of women ages 15–49
This indicator measures the percent of women ages 15–49 who have completed at least a
primary level of education. For different countries, primary education may vary from four
years to eight to ten years.
Antenatal:
ACHH I-3. Percent of mothers of children aged 0–23 months in catchment area that saw a
skilled provider three or more times during last pregnancy*
Key Indicator Definition: Numerator: number of mothers of children aged 0–23 months
in catchment area that saw a skilled provider three or more times during last pregnancy.
Denominator: number of mothers of children aged 0–23 months.
ACFL I-4. Percent of mothers with children age 0–23 months who received at least two
tetanus toxoid injections before the birth of their youngest child*
Key Indicator Definition: Numerator: number of mothers with children age 0–23 months
who received at least two tetanus toxoid injections before the birth of her youngest child
(confirmed by maternal health card). Denominator: Number of mothers with children age
0–23 months.
ACSL I-7. Percent of health facilities with skilled attendant (doctor, nurse or midwife) avail-
able 24 hours per day, seven days per week
(MOV: HFA)
Key Indicator Definition: Numerator: number of health facilities with skilled attendant
(doctor, nurse or midwife) available 24 hours per day, seven days per week. Denominator:
number of health facilities.
Appendix I: Key Indicators 73

Labor and Delivery:
LDHH I-15. Percent of children aged 0–23 months whose delivery was attended by a skilled
health personneli*
Key Indicator Definition: Numerator: Number of women who delivered with a doctor,
nurse, midwife, or auxiliary midwife; Denominator: Total number of children aged 0–23
months.
LDCL I-1. Percent of communities with an emergency transport plan in place

Key Indicator Definition: Numerator: Number of communities that have an emergency
transport system; Denominator: Number of communities
Postpartum:
PPHH I-16. Percent of mothers and newborns who received postpartum care at each recom-
mended interval from skilled personnel***
(MOV: population-based survey; HF records; client or exit interviews)
Key Indicator Definition: Numerator: number of women attended at each postpartum inter-
val by skilled personnel; Denominator: number of live births
PPCL I-1. Percent of communities that have an emergency transport system

Key Indicator Definition: Numerator: Number of communities that have an emergency
transport system; Denominator: Number of communities
PPSL I-1. Percent of health facilities with skilled attendant (doctor, nurse or midwife) avail-
able 24 hours per day, seven days per week
(MOV: HFA)
Key Indicator Definition: Numerator: number of health facilities with skilled attendant
(doctor, nurse or midwife) available 24 hours per day, seven days per week; Denominator:
number of health facilities
Newborn Care:
NCHH I-3. Percent of children aged 0–23 months who were immediately breastfed at birth*
Key Indicator Definition: Numerator: Number of children breastfed within the first hour
after birth; Denominator: Number of children aged 0–23 months
NCHH I-5. Percent of children aged 0–23 months whose delivery involved use of a clean
birth kit or whose cord was cut with a new razor*
Key Indicator Definition: Numerator: Number of children aged 0–23 months whose deliv-
ery involved use of a clean birth kit or whose cord was cut with a new razor; Denominator:
Number of children aged 0–23 months

NCHH I-7. Percent of newborns who receive postnatal care from a skilled provider at each
recommended interval**
Key Indicator Definition: Numerator: Number of newborns who receive postnatal care from
a skilled provider at each recommended interval; Denominator: Number of live births
Appendix I: Key Indicators 75

Appendix II
Programming for Maternal
and Newborn Health
A
ppendix II presents an overview of designing programs for maternal and newborn
health. Topics include using frameworks in program design, program planning, sta-
tus analysis/needs assessments, and selecting indicators. Basic information about the
causes of maternal and newborn mortality and the evidence-based interventions that address
these causes is provided. There is also a brief discussion about skilled birth attendants and
HIV/AIDS. Additional resources are listed at the end of the Appendix in the Essential
References.
I. Using Frameworks in Program Design

Well-designed programs are developed using a framework of some kind, and are typically
ordered by an overarching goal (which cannot be measured), main objective(s), and lower-
level objectives. For each objective, related activities and indicators are selected to address
and measure the progress toward achieving the objective. While NGOs may use different
terminologies and frameworks to design programs, most approaches share the common ele-
ments just described.
A. Results Framework
USAID, many of its CAs, and USAID-supported NGOs are familiar with, and use, the
Results Framework. In Results Framework terminology, the objectives are stated as desired
results. The main objective is referred to as a Strategic Objective (SO), and the lower-level
or dependent objectives are referred to as Intermediate Results (IRs). The causal relationship
between the IRs and SO is direct and clear: the lower level results must be achieved in order
for the SO to be realized.
An excellent explanation of the Results Framework and examples are found in Health
and Family Planning Indicators: A Tool for Results Frameworks, Vol. 1 prepared by the
Office of Sustainable Development for the Africa Bureau at USAID on the following web-
site: http://www.dec.org/pdf_docs/PNACM806.pdf. Save the Children/USA, an international
NGO, has adopted the generic framework in A Tool for Results Frameworks as the basis for
designing its reproductive health programs (see Figure 1).
According to a Senior Reproductive Health Advisor at Save the Children, most successful
health programs can be shown to be a result of improving/increasing access, quality, interest
and knowledge for services (formerly referred to as ‘demand’), and improving the social and
policy environment. The SO and IRs are typically refined for specific programs.
Appendix II: Programming for Maternal and Newborn Health 77

Figure 1: Generic Results Framework
Goal: Improved Health Status
SO: Improved Use of Key Health Services and Practices/Behaviors
IR3:
IR1: Increased
IR4:
Increased IR2: knowledge of,
Improved social
access/ Increased improved attitudes
and policy
availability of quality of toward, and
environment
health health services acceptance of
services/supplies key services and
behavior
B. Designing Programs by Objective (Desired Outcome)

Another international NGO, CARE, has developed a strategic approach to designing pro-
grams based on the desired outcome(s) (or objective) to be achieved. For example, if a pro-
gram focuses on “reducing maternal and newborn mortality”, a program designer would
select a set of interventions that are more directly linked to reducing mortality. If a program
focuses on “health promotion” a program designer may select a larger set of interventions
that may not directly reduce mortality (although their health promotion effects may indi-
rectly reduce maternal and neonatal illness and deaths).
Table 1 illustrates what interventions contribute to desired program outcomes
(objectives).
Reducing mortality and promoting health do not have to be mutually exclusive, but it
needs to be understood that the selection of interventions may differ depending on the over-
all objective. Program planners need to have clear goals, so that appropriate interventions
can be selected to achieve their objectives.
Figure 2 on page 80 presents a Program Design for the Prevention of Maternal Mortality
at the Community and Facility Levels in a logframe format that CARE developed. Note that
the terminology in Figure 2 differs somewhat from the “Results Framework” terminology
presented earlier. However, if you turn Figure 2 sideways so that the impact goal is at the
top, you can compare and contrast the relationship between the two approaches.

Table 1: Selecting Interventions by Desired Outcome
(Objective)
Objective: Objective: Objective:
Interventions Maternal Health Maternal Mortality Newborn
Family Planning X X
Antenatal Care X X
Safe Delivery X X X
Emergency X X X
Obstetric Care
Post-Partum Care X X
Post-Abortion Care X
Newborn Care X X
Source: CARE’s Guide for the Use of Maternal and Newborn Health Planning Tools prepared by
Susan Rae Ross.
The point is that no matter what framework or system an NGO or program planner uses
to design a program, what matters is that the program is designed with 1) clear goals and
objectives, 2) the ‘causal’ pathway linking activities and objectives is carefully considered
and the linkages between them are clearly laid out in the project plan.
II. Overview of Program Planning

For programs to be successful, they are best designed with the participation of stakeholders
from the beginning stages of a project. For a summary of a good approach to overall pro-
gram planning, see Table 2.
III. Situational Analysis/Needs Assessment

As part of the situational analysis/ needs assessment, data from both primary and secondary
sources can be analyzed to determine what strategies and interventions should be selected to
improve maternal and newborn health. Table 3 summarizes the key indicators to consider
when conducting a needs assessment, and the limits for areas of high, moderate, and low
need for intervention.

Figure 2: Illustrative Program Design for Prevention
of Maternal Mortality at the Community and Facility Levels
Activities Supporting Objectives Intermediate Goals Final Project
80
(Processes) (Outputs) (Outcomes/Effects) Goal (Impact)
Plan and implement BCC strategy, Community members with Increased use of birth planning
including development and increased knowledge of and and preparation to deal with
dissemination of IEC materials (with support for birth planning and obstetric emergencies
an emphasis on birth planning) recognition of danger signs
Develop and implement community Community plans in place for Increased use of community
support systems (transportation/ supporting women and their support for seeking EmOC when
pregnancy and monitoring/ savings families during an obstetric required
& loans for emergency care) emergency
Service providers and communities Increase in met

Develop/strengthen partnership Community members and need for Emergency
working together to advocate for,
between community-based providers know where to refer;
manage and provide quality Obstetric services
providers and referral facilities facilities accept referrals
services
Train TBAs and community TBAs and community members

Increased referrals by
members to recognize danger with the knowledge and skills
TBAs/families to appropriate
signs for immediate referral required to recognize danger signs
facilities
and refer immediately
Develop protocols and train Providers with the skills required Increase in the proportion of Decrease in Case
facility-based providers to manage managing obstetric emergencies in appropriately managed obstetric Fatality Rate in
obstetric emergencies accordance with protocols cases facilities

Supervisors able to demonstrate Increased use of supportive
Develop/strengthen and coaching and supervisory skills; supervision and on the job
implement supervision systems plan in place for performing learning; higher level of skills
regular supervisory visits among providers
Develop/strengthen and Providers and community members

implement MIS system to monitor with increased knowledge of Increase in effective use of data
pregnancies, deliveries, maternal data and use of data for for program management
emergency care and outcomes managing service delivery and care
Table 2: CARE’s Programming Approach
Situational Analysis
• Review the context of maternal/neonatal health in regards to the overall devel-
opment conditions in the local situation
• Design and collect primary data, in consultation with communities and provid-
ers, both qualitative (for example, verbal autopsies, Participatory Learning
Appraisal (PLA)) and quantitative (i.e., Knowledge, Attitudes, Practices (KAP))
• Review secondary data, both qualitative and quantitative
• Conduct an environmental assessment (assess what other organizations are
doing, donor priorities and NGO’s strengths)
• Select potential project areas based on objective criteria
• Begin discussions regarding potential partnerships
Project Design
• Analysis of data for the development of major program strategies
• Project design including an analytical framework (e.g., results framework,
logframe, etc.) selection of evidenced based interventions, a monitoring and
evaluation plan
• Donor approval/ Government endorsement/ Community commitment
Project Implementation
• Implementation and monitoring, in partnership, of selected interventions and
their relevant output and effect indicators, with a feedback mechanism to pro-
vide refinement throughout implementation
• Mid-term Evaluation, focusing on process indicators, and development of a
plan to adjust implementation, as required
• Ongoing documentation and dissemination of lesions learned, both successes
and failures
• Final Evaluation, focusing on effect level (outcome) indicators, and develop-
ment of a plan to adjust implementation, as required
• Post-Project Evaluation, focusing on impact level
Source: CARE’s Guide for the Use of Maternal and Newborn Health Planning Tools prepared by
Susan Rae Ross.

Table 3: Needs Assessment for Maternal and Newborn Health
Moderate
Data High Need Need Low Need
Women’s Status
Literacy (% female literacy) <35% 35–60% >50%
Economic Status— No access Limited access Access
Access to income
Decision Making— None Limited Participation
Involvement level
Health Status/ Infrastructure
Maternal Mortality Ratio (MMR) >500 350–499 <350
Infant Mortality Rate (IMR) >80 65–79 <65
Total Fertility Rate (TFR) >5.0 4.0–4.9 <4.0
Low Birth Weight (LBW) >35% 20%–34% <20%
(<2,500 gms)
Syphilis prevalence in pregnancy >15% 5–15% <5%
HIV prevalence in pregnant women >10% 2–10% <2%
Malaria Prevalence
Any season >10% 2–10% <2%
Rainy season >20% 20% –
Health Service Availability
Number of Skilled Providers/per <15 15–30 >30
10,000 population
Basic Emergency Obstetric Care: <50% 50–80% >80%
percent of population within
5 miles of health center
Comprehensive Emergency Obstetric None >4 hours travel <4 hours travel
Care: travel time to facility
Outreach services (FP, ANC, EPI): <50% 50–80% >80%
percent of population within 3 miles
If Available, Are Services Used? — Service Utilization
Antenatal care (ANC): >3 visits <35% 35–50% >50%
Pregnant women who are anemic >45% 30–45% <30%
Contraceptive prevalence rate (CPR) <25% 25–35% >35%
Unmet Need for family planning >25% 20–25% <20%
Deliveries w/skilled provider <35% 35–50% >50%
Postpartum care/Vitamin A <35% 35–50% <50%
If Services Are Not Used, Why Not? — Knowledge
Knowledge of family planning: <35% 35–50% >50%
source and methods
Knowledge of danger signs of <35% 35–50% >50%
pregnancy and childbirth
Knowledge of the importance of <35% 35–50% >50%
ANC, clean delivery, and PPC
Source: CARE’s Guide for the Use of Maternal and Newborn Health Planning Tools prepared
by Susan Rae Ross.

IV. Selecting Indicators to Measuring Program
Effectiveness
Selecting the right indicators is key to good program design. The following passages are
taken from the document, A Quick Guide to Assessing the Effectiveness of PVO Safe
Motherhood, Family Planning, and Reproductive Health Interventions prepared by Donna
Espeut of the Child Survival Technical Support (CSTS+) Project. This document is available
on the CSTS+ web site at www.childsurvival.com.
There are two main reasons to assess program effectiveness:
1. To determine progress toward results (program monitoring)
2. To evaluate whether program objectives have been achieved (program evaluation).
The following steps are important in defining program effectiveness:
1. Determine the desired end result(s) that the project is trying to achieve (for example,
more women having birth intervals of an adequate length) and the corresponding inter-
mediate results (for example, no stockouts of family planning methods and essential
supplies at health facilities; access to birth spacing services; demand for birth spacing
methods; and provision of family planning services to post-abortion women).
2. “Operationalize” the results through the program objectives and indicators. The indica-
tors should match your program activities and objectives. For example, if your project is
trying to promote longer birth intervals, this result may be operationalized through the
following indicator: the percentage of women whose youngest two children were born
at least 36 months apart.
The following are some guiding questions to ask when selecting indicators:
• Is the indicator state-of-the-art?
• Does it reflect the latest national and international standards?
• Is it valid? Does it measure what it’s supposed to measure?
• Is it reliable? Can it be measured consistently across enumerators and/or across time?
• Is it operational? Is it clearly defined in terms of what you are trying to achieve, and in
which target group?
• Is it feasible? Are the data required to calculate the indicator available and of good
quality?
• Does it match your program activities and targets?
• Does it sufficiently reflect the relationship between your intervention and the desired
end result?
V. Select Background Information for Maternal and

Newborn Programming
A. Maternal and Newborn Care Are Linked
Table 4 illustrates the direct relation between maternal conditions and maternal and neona-
tal outcomes (without intervention). Midwives and other clinicians frequently refer to the
mother and newborn as the “mother-baby dyad”, a phrase that suggests that the care of the
mother and newborn cannot be readily compartmentalized or separated if optimal care is
to be provided.

Table 4: Maternal Conditions and Potential Maternal and
Perinatal Outcomes
Potential Maternal Potential Perinatal/
Outcome without Neonatal Outcome
Intervention Maternal Condition Without intervention
During Pregnancy
Contributing to anemia  Folic Acid Deficiency  Stillbirths, neural tube

defects
Night blindness  Vitamin A Deficiency  LBW, neonatal sepsis
Anemia,  likelihood
hemorrhage  Iron Deficiency  LBW, anemia
Anemia  Hookworm  LBW
Potential Infertility  Gonorrhea  Preterm delivery,
 Chlamydia  neonatal eye infection,
blindness, pneumonia,
stillbirth
 CMV  Preterm delivery,
 Bacterial Vaginosis  stillbirth
HIV/AIDS  HIV/AIDS  MCTC
Infertility, heart  Syphilis  Preterm delivery,
abnormalities, blindness, neonatal eye infection,
neurological problems, blindness, stillbirth,
death congenital syphilis,
Hepatitis,  likelihood  Hepatitis/Jaundice  Sever jaundice, hepatitis
of hemorrhage
Anemia  Malaria  Prematurity, intrauterine
growth retardation,
stillbirth
Convulsions, death  Pre-Eclampsia  Stillbirth, asphyxia
Unsafe abortion  Unwanted Pregnancy  Increased risk of
Pregnancy morbidity from abuse,
neglect
During Labor
Maternal Infection,  Unclean Delivery:  Neonatal infection,

sepsis leading to death Environment sepsis leading to death
 Unclean delivery:  Neonatal tetanus,
Cord Care neonatal sepsis leading
to death
Maternal Infection  Premature Rupture  Neonatal infection
leading to sepsis of Membranes (PROM) leading to sepsis
Prolonged labor, vaginal  Malpresentation  Meconium, asphyxia,
tears, C-Section, birth traumas
potential death
Convulsions, death  Pre-Eclampsia  Stillbirth, asphyxia
Uterine rupture  Obstructed Labor  Asphyxia, stillbirth, sepsis,
birth trauma handicap
During Postpartum
Slowed uterine atonement;  No Colostrum Feed  Delayed suck reflex;

engorged breasts  loss of nutrients, potential
reduction in lactation for hypothermia
PPH leading to death  Retained Placenta 
Convulsions leading to death  Pre-Eclampsia/ Eclampsia 
Sepsis leading to death  Infection 
Source: CARE, The Healthy Newborn: A Reference for Managers, 2002

B. The Timing of Interventions for Maternal and Newborn Care
Figure 3 shows the timing of stages of pregnancy and infant life, as well as the timing of
maternal and newborn care interventions.
Figure 3: Timing of Maternal and Newborn Care Interventions
Intervention Package for Time Periods of Pregnancy, Neonatal, and Infant Life
BIRTH
Conception 20 wks 28 wks 4 wks One year
Early Late Neonatal Post-

Miscarriage
fetal fetal early/late neonatal
Perinatal
(22 weeks gestation to
7 days after birth)
Infant
Fetal-infant
Pre- Care Newborn &

Care during
pregnancy during postpartum Infant care
pregnancy
health deliver care
Stillbirths = babies born dead after 22 weeks of gestation (birth weight more than 500 g)
(Note: WHO recommends international reporting of fetal deaths only for those more than 28 weeks/[1kg])
C. Evidence-based Interventions for Reducing Maternal Mortality

The major causes of maternal mortality and the key evidence-based interventions for
addressing these causes are shown in Figure 4.
Figure 4: Evidence-based Interventions for

Major Causes of Maternal Mortality
Family planning and

postabortion care
Magnesium sulfate
Unsafe
Antibiotics abortion
Tetanus Toxoid 13%
Immunization Infection Eclampsia
Clean delivery 15% 12%
Obs. labor
Partogram 8% Severe
bleeding Active
Other direct 24% management * Other direct causes include:
causes of the third ectopic pregnancy, embolism,
8%* stage of labor
Indirect anesthesia-related
causes
20%** ** Indirect causes include: ane-
mia, malaria, heart disease
Source: Adapted from “Maternal
Health Around the World”
Iron supplements, malaria intermittent
World Health Organization,
treatment and antiretrovirals for HIV Geneva, 1997

Postpartum hemorrhage (PPH) is the largest contributor to maternal mortality. There are
evidence-based, feasible low-cost interventions that can reduce the morbidity and mortality
due to PPH. These set of interventions are collectively referred to as the active management
of the third stage of labor.
Active management of the third stage of labor includes the following interventions to be
administered by a skilled birth attendant:
• Administering a uterus-contracting drug such as oxytocin, misoprostol within one
minute of birth;
• Applying controlled cord traction and counter traction to the uterus;
• Massaging the fundus of the uterus though the abdomen; and
• Monitoring for further signs of bleeding.
D. Evidence-based Interventions for Major Causes of Neonatal

Mortality
One-third of deaths of children under five occur during the first 28 days of life (neonatal
period). While some advances have been made in improving the survival of infants after the
neonatal period up to 12 months, less improvement has been shown for infants younger
than 28 days.
The major causes of neonatal mortality and the key evidence-based interventions for
addressing these causes are shown in Figure 5.
Figure 5: Evidence-based Interventions for Major Causes of

Neonatal Mortality
• Syphilis control
• Folate supplementation
• Tetanus Toxoid
Immunization of mother
• Clean delivery
Cong. • Cord care
Anom.
• Early and exclusive breastfeeding
10%
Infection • Antibiotics
32%
• Birth spacing
• Maternal nutrition Tetanus
• Malaria control Complications Sepsis
of prematurity Respiratory infection
• Kangaroo care Diarrhea
24%
Other Birth asphyxia

5% and injuries
29%
• Warming
• Resuscitation
• Skilled birth attendants
Low birth weight is a significant

contributor in 40–70% of neonatal deaths
Source: Zupan, Jelka, WHO, 2001.

VI. Skilled Birth Attendants and Traditional Birth
Attendants (TBAs)
According to WHO, the term ‘skilled attendant’ refers to “a health professional-—such as
midwife, doctor or nurse—who has been educated and trained to proficiency in the skills
needed to manage normal (uncomplicated) pregnancies, childbirth and the immediate post-
natal period, and in the identification, management or referral of complications in women
and newborns.”i Although universal access to a skilled attendant at birth is a worthy goal,
the reality is quite different in many countries. In fact, less than 60% of all births in develop-
ing countries are attended by a skilled health provider.ii
It is important to note that formal health care personnel, such as doctors, nurses, etc., are
not automatically “skilled birth attendants.” Some doctors and nurses may not have had any
obstetric training, or may not have mastered these skills. TBAs help to fill the gap, although
some have concerns about the quality of care they are able to provide.
The term ‘traditional birth attendant’ refers to a lay health care provider who assists
mothers during childbirth. They may have no formal training, or they may have been trained
in basic obstetric care through a six-week course; regardless, most learn their skills through
experience.iii TBAs are generally valued in communities because of their knowledge of—and
experience with—childbirth. Nevertheless, according to WHO, TBAs are not eligible to
be classified as skilled birth attendants, regardless of whether or not they have received
training.
Supportive roles for TBAs are being sought in some areas, including the avoidance of
harmful practices, providing health education—including the recognition of danger signs—
and referring women who are experiencing complications.iv Many NGOs involve TBAs in
health education and community mobilization efforts. Some NGOs also involve TBAs in
the promotion of exclusive breastfeeding and the distribution of family planning methods.
Lastly, a few NGOs are training TBAs in emergency obstetric first aid, including skills such
as newborn resuscitation.
The American College of Nurse-Midwifes (ACNM) promotes the use of emergency obstet-
ric aid as part of its Home-based Life Saving Skills package. As part of this package, eligible
TBAs and other selected community and family members receive training in groups—pri-
marily through role play—to reinforce key actions to reduce maternal mortality.
If a project plans to work with TBAs, it is important for program designers and manag-
ers to understand national and local policies concerning TBAs, as well as their relationships
with the communities they serve.

VII. Maternal and Newborn Care in HIV/AIDS
Affected Areas
Figure 6 shows the links between essential maternal and newborn care and the prevention
of mother-to-child transmission (PMTCT) of HIV infection.
Figure 6: Integration of Essential Maternal and Newborn Care

and PMTCT
Antenatal care Intrapartum care Postnatal care
• Maternal • Clean delivery • Special care of

nutrition, (including LBW baby
including prophylaxis for (thermal
micronutrients infection, e.g., protection, Reduced:
• Syphilis chlorhexidine, infection • Maternal
detection and antibiotic) prevention and and
treatment • Prevention/ treatment) newborn
• Intermittent management of • Exclusive infection
presumptive newborn breastfeeding • Asphyxia
EMNC
treatment for hypothermia • Immunization • Low birth

malaria* • Early and • Maternal weight
• Breastfeeding exclusive nutrition • Postpartum
counseling breastfeeding • Birth hemorrhage
• Prophylaxis, • Active manage- spacing/family • Maternal
detection, & ment of the planning Anemia
treatment of third stage of counseling
opportunistic labor • Prophylaxis,
infections • Partogram detection, and
• Tetanus toxoid • Resuscitation treatment of
• Birth • Prophylactic eye opportunistic Reduced
preparedness care* and puerperal maternal, fetal
• Emergency infections and
obstetric care neonatal
deaths
Pregnancy Labor and birth Postpartum
Reduced:
• Keep delivery • Early & exclusive Maternal-to-
PMTCT
normal breastfeeding child-

• Minimize invasive • Or breastfeeding transmission
procedures alternatives of HIV
(AROM**, • Care for
episiotomy, mastitis/thrush
suctioning, • Rapid cessation
trauma) of breastfeeding
• Family planning
Short Course ARV prophylaxis
VCT, prevention of infection

(TB, STI, safer sex, partner involvement)
* endemic areas.
** AROM: artificial rupture of membrane.
Bold, italicized sentences indicate evidence based basic care package for HIV infected
women and HIV exposed newborns.
Source: Compiled by Lily Kak, USAID/GH.

While all the Standards and Indicators presented in the Compendium are applicable to
HIV-affected areas, program designers should consult appropriate resources for the most
recent updates in care and treatment and the recommended indicators to use. A compre-
hensive source of information for NGOs implementing programs is the HIV/AIDS Virtual
Resource Center available on the CSTS + website: http://www.childsurvival.com/vrc/. The
center has links to key web sites devoted to HIV/AIDS.
NGOs working in HIV/AIDS-affected areas should consider addressing the need for
confidential, high-quality voluntary counseling and testing (VCT) for HIV—strengthening
services where they exist and working with local health providers to establish them where
they are not. VCT is a cornerstone of HIV/AIDS programming, and ensuring access to a
confidential, high-quality VCT service is critical to making a positive impact on health.
VIII. Essential References

A Quick Guide to Assessing the Effectiveness of PVO Safe Motherhood, Family Planning,
and Reproductive Health Interventions. Donna Espeut. Calverton, Maryland: Child
Survival Technical Support (CSTS+) Project, ORCMacro, 2003.
www.childsurvival.com.
Assessing Maternal and Peri-Neonatal Health: Tools and Methods: The MotherCare
Experience. Abigail Harrison. Arlington, Virginia: MotherCare, 1994.
Assessing Safe Motherhood in the Community: A Guide to Formative Research. Nancy
Nachbar, Carol Baume, Anjou Parekh. Arlington, Virginia: MotherCare, 1998.
Basic Maternal and Newborn Care: A Guide for Skilled Providers. Barbara Kinzie and
Patricia Gomez. Baltimore, Maryland: Maternal and Neonatal Health, JHPIEGO,
2004. www.jhpiego.org
Beyond the Numbers: Reviewing Maternal Deaths and Complications to Make Pregnancy
Safer. Geneva: WHO, 2004. http://www.who.int/reproductive-health/publications/btn/
index.html
Care of the Newborn: Reference Manual. Diana Beck, Frances Ganges, Susan Goldman,
Phyllis Long. Washington, DC: Saving Newborn Lives, Safe the Children, 2004.
www.savethechildren.org and www.healthynewborns.com
Family Planning Virtual Resource Center. Child Survival Technical Support Project
(CSTS+) Calverton, Maryland: ORCMacro, 2004. www.childsurvival.com/fpvrc/
HIV/AIDS Virtual Resource Center. Child Survival Technical Support Project (CSTS+)
Calverton, Maryland: ORCMacro, 2004. www.childsurvival.com/vrc/
How to Mobilize Communities for Health and Social Change: A Field Guide. Lisa
Howard-Grabman. Baltimore, Maryland: Health Communication Partnership, 2003.
Integrating Prevention of Mother-to-Child HIV Transmission into Existing Maternal,
Child and Reproductive Health Programs. Technical Guidance Series, Number 3. Ellen
Israel and Mary Kroeger. Watertown, Massachusetts: Pathfinder International, 2003.
http://www.pathfind.org/site/DocServer/Technical_Guidance_Series_3_PMTCTweb_
01.pdf?docID=242
Igniting Change!: Accelerating Collective Action for Reproductive Health and Safe
Motherhood. Nancy Russell and Marta Levitt-Dayal. Washington, DC: ENABLE
Project, CEDPA, 2003. www.cedpa.org

Managing Complications in Pregnancy and Childbirth: A Guide for Midwives and
Doctors. Integrated Management of Pregnancy and Childbirth (IMPAC). WHO/
RHR/00.7. Matthews Mathai, Harshad Sanghvi, Richad Guidotti. Geneva:
Department of Reproductive Health and Research, World Health Organization, 2000.
www.who.org
Managing Newborn Problems: A Guide for Doctors, Nurses, and Midwives. Integrated
Management of Pregnancy and Childbirth. Geneva: Department of Reproductive
Health and Research, World Health Organization, 2003. www.who.org
Monitoring Reproductive Health: Selecting a Short List of National and Global Indicators.
WHO/RHT/HRP/97.26. Geneva: Division of Reproductive Health, World Health
Organization, 1997.
Partnership-Defined Quality: A Tool Book for Community and Health Provider
Collaboration for Quality Improvement. Ronnie Lovich, Marcie Rubardt, Debbie
Fagan, Mary Beth Powers. Westport, Conn: Save the Children, 2003.
Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential Practice.
Integrated Management of Pregnancy and Childbirth. Geneva: Department of
Reproductive Health and Research, World Health Organization, 2003. www.who.org
Preventing Postpartum Hemorrhage: Toolkit for Providers (Condensed Version).
Washington, DC: PATH, 2004. www.path.org
Promoting Quality Maternal and Newborn Care: A Reference Manual for Program
Managers. Susan Rae Ross. Atlanta, Georgia: CARE, 1999. www.care.org
Safe Motherhood Needs Assessment. WHO/RHT/MSM/96.18. Geneva: WHO, 1998.
Saving Mothers, Saving Children—Preventing Maternal to Child Transmission of HIV/
AIDS: A Guide for Working in the Community (Draft). HIV/AIDS Working Group
and Safe Motherhood and Reproductive Health Working Group, Child Survival
Collaborations and Resources (CORE) Group. Washington, DC: The CORE Group,
2004.
Saving Mothers’ Lives: What Works: A Field Guide for Implementing Best Practices in
Safe Motherhood. India: The White Ribbon Alliance for Safe Motherhood, 2003.
Saving Lives: Skilled Attendance at Birth at Childbirth: Report on an International
Conference Organized by the Safe Motherhood Inter-Agency Group 13–15 November
2000, Tunis, Tunisia. New York: Family Care International, 2001. http://www.
safemotherhood.org/resources/pdf/skilled_care/Saving_Lives_ConfReport_Eng.pdf
Selecting Reproductive Health Indicators: A Guide for District Managers. WHO/RHT/
HRP/97.25 Dist: General. Geneva: Division of Reproductive Health Technical
Support, World Health Organization, 1997.
Shaping Policy for Maternal and Newborn Health: A Compendium of Case Studies.
Baltimore, Maryland; JHPIEGO, 2003.
The Healthy Newborn: A Reference Manual for Program Managers. Joy Lawn, Brian
McCarthy, Susan Rae Ross. Atlanta, Georgia: CARE/Centers for Disease Control
(CDC) Health Initiative, 2003. www.cdc.gov/nccdphp/drh.
What Works: A Policy Guide and Program Guide to the Evidence on Family Planning,
Safe Motherhood, and STI/HIV/IADS Interventions: Module 1: Safe Motherhood. Jill
Gay, Nicole Agarwal, Katerine Fleming, Alana Hairston, Brettania Walker, Martha
Wood. Washington, DC: The Policy Project, 2003. www.policyproject.com

Helpful web sites:
• American College of Nurse Midwives (www.acnm.org)
• Averting Maternal Death and Disability Project (http://cpmcnet.columbia.edu/dept/sph/
popfam/amdd/index.html)
• CARE (www.care.org)
• Child Survival Technical Support (CSTS+) Project (www.childsurvival.com)
• CORE Group (www.coregroup.org)
• INFO (www.infoforhealth.org)
• JHPIEGO (www.jhpiego.org)
• Maximizing Access and Quality (MAQ) (www.maqweb.org)
• Oxfam (www.oxfam.org.uk)
• Partnership for Safe Motherhood and Newborn Health (www.safemotherhood.org)
• Population and Health Infoshare (http://www.phishare.org/)
• Reproductive Health Gateway (www.rhgateway.org)
• Save the Children (www.savethechildren.org)
• Saving Newborn Lives (http://www.savethechildren.org/health/newborns/index.asp)
• The Policy Project (www.policyproject.com)
• White Ribbon Alliance for Safe Motherhood (www.whiteribbonalliance.org)
• World Health Organization (www.who.int)
Endnotes
i. Ibid.
ii. This definition was adapted from “The critical role of the skilled attendant: a joint statement by
WHO, ICM and FIGO”. World Health Organization, Geneva 2004 (draft).
iii. Skilled attendant at birth – 2004 global estimates. WHO; http://www.who.int/reproductive-
health/global_monitoring/skilled_attendant.html
iv. Haws R, PJ Winch, J Castillo, Innovative Community-based Interventions to Improve Newborn
Health in Latin America and the Caribbean. The CORE Group: 2004; www.coregroup.org
v. Ibid.

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Maternal and Newborn

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Table of Contents iii

Erin Anastasi, ADRA Debbie Herold, ADRA

vi Maternal and Newborn Standards and Indicators Compendium

ACNM American College of Nurse-Midwives

viii Maternal and Newborn Standards and Indicators Compendium

Prepared by Virginia Lamprecht, RN, MSPH, MA

What is the Purpose of the Compendium?

2 Maternal and Newborn Standards and Indicators Compendium

How Can the Compendium of Standards and

Future Editions of this Compendium

4 Maternal and Newborn Standards and Indicators Compendium

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

See also PCHH I-1 – I-10, I-14, I-17 – I-27

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

* Source: taken directly or derived from KPC 2000+; CSTS, CORE.

Maternal and Newborn Standards and Indicators Compendium

• Education for girls

Intervention Focus: Preconception/Inter-Conception Care 15

16 Maternal and Newborn Standards and Indicators Compendium

Intervention Focus: Preconception/Inter-Conception Care 17

18 Maternal and Newborn Standards and Indicators Compendium

Intervention Focus: Preconception/Inter-Conception Care 19

Maternal and Newborn Standards and Indicators Compendium

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Maternal and Newborn Standards and Indicators Compendium

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

Also see ACCL I-1 – I-3.

Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND

* Source: derived or taken directly from KPC 2000+; CSTS, CORE

Maternal and Newborn Standards and Indicators Compendium

28 Maternal and Newborn Standards and Indicators Compendium

Intervention Focus: Antenatal Care 29

30 Maternal and Newborn Standards and Indicators Compendium

Intervention Focus: Antenatal Care 31

32 Maternal and Newborn Standards and Indicators Compendium

Intervention Focus: Antenatal Care 33

34 Maternal and Newborn Standards and Indicators Compendium

RECOMMENDED PRACTICES AND