Count every newborn; a measurement improvement roadmap for coverage data

To achieve this, ambitious improvement of data on care at birth and small and sick newborns is required, particularly to track coverage, quality, and equity. ENAP published 10 core indicators plus 10 additional indicators, with three core impact indicators (neonatal mortality rate, maternal mortality ratio, stillbirth rate) well defined, but requiring future efforts to improve data quantity and quality. Three core indicators on coverage of care for all mothers and newborns (intrapartum/skilled birth attendance, early postnatal care, essential newborn care) have defined contact points, but gaps exist in measuring content and quality of the interventions. Four core (antenatal corticosteroids, neonatal resuscitation, treatment of serious neonatal infections, kangaroo mother care) and one additional coverage indicator for newborns at risk or with complications (chlorhexidine cord cleansing) lack indicator definitions or data, especially for denominators (population in need). To address these gaps, feasible coverage indicator definitions are presented for validity testing, along with measurable process indicators to help monitor health service readiness. A major measurement gap exists to monitor care of small and sick babies, yet signal functions could be tracked similarly to emergency obstetric care. The ENAP Measurement Improvement Roadmap (2015-2020) outlines tools to be developed (e.g., improved birth and death registration, audit, and minimum perinatal dataset) and actions to test, validate, and institutionalise proposed coverage indicators. The roadmap presents a unique opportunity to strengthen routine health information systems, crosslinking these data with civil registration and vital statistics and population-based surveys. The Every Newborn Action Plan (ENAP) is a global multi-partner movement to end preventable maternal and newborn deaths and stillbirths. Through a series of consultations, multiple stakeholders developed an impact framework and an action and measurement agenda for integration within national newborn health plans. To reach 2030 national targets for neonatal mortality and stillbirth rates of ≤12 per 1000 births, high and equitable coverage of the evidence-based interventions identified by ENAP is needed, particularly during childbirth and the first week of life. ENAP prioritises achieving universal coverage of these interventions, yet many of these interventions are not systematically measured. One of the five ENAP strategic objectives - to count every newborn (and birth) - underlines the need for improved data and accountability. The ENAP milestones, linked to a World Health Assembly resolution, have a particular focus on inputs required prior to 2020 and more than half refer to improving metrics for targeting and driving change. The principal focus of this paper is based on the ENAP milestone to define and improve priority coverage indicators, as this was where the largest measurement gaps were identified. Many newborn care interventions lack standard indicator definitions and are not routinely monitored at national or global level, especially in low and middle-income countries (LMIC). Coverage indicators are defined as population-level metrics that measure the number of individuals that receive an intervention or service (numerator) out of a total population that should receive the intervention or service (the denominator). For the numerator, indicators rely on clear technical definitions of the service or intervention, while the denominator may use total live births as a proxy, especially when capturing the population in need is difficult. The coverage indicators prioritised by the Commission for Information and Accountability (COIA) mainly reflect contact points along the continuum of care, notably antenatal care, skilled birth attendance, and postnatal care. Such coverage indicators capture contact with the health system or delivery of a specific intervention, but not always detailed, accurate information on the content or quality of the care delivered. In high-burden countries, the main current data source is through household surveys, such as the United States Agency for International Development (USAID)-supported Demographic and Health Survey (DHS) and the United Nations International Children's Fund (UNICEF)-supported Multiple Indicator Cluster Survey (MICS). However, coverage of many maternal and newborn interventions cannot feasibly and/or accurately be collected through household surveys.