SMI 36-Month Results: Honduras Performance Indicator Results Pass Targets

Salud Mesoamerica Initiative:
Select results from the second
operation measurement
November 8, 2018
Ali H. Mokdad, Ph.D.
Chief Strategy Officer of Population Health
Director, Middle Eastern Initiatives
Professor, Global Health

Outline
• Introduction
• SMI 36-Month Challenges
• SMI 36-Month Results
• Conclusions and Future Activities
3

SMI Evaluation status
• Completed SMI baseline measurement
2011-2013
• Completed first follow-up measurement
2014-2015
• Conducted SMI Process Evaluation in
Chiapas, Mexico 2016
• Completed second follow-up measurement
2017-2018
• Published 19 research articles

SMI evaluation design
Baseline
HH & HF
surveys
2011-2013
0 months
2014
18 -months
2017-2018
36-months
2020
54-months
Interventions
commence
Follow-up
HF
surveys
Follow-up
HH & HF
surveys
Follow-up
HH & HF
surveys
1 2 3
5

Activity flowchart
Study and survey design (IHME)
• Fact-finding visits
• Instrument design
• CAPI (real-time data collection)
• Training and pilots
• Sampling
• Quality checks
Data collection (in-country agencies)
• Community census
• Household survey
• Health facility survey
• Supervision by IHME
Analysis (IHME)

Census
• Full household listing for selected
segments
• Strict protocol for visits
• Response rates monitored
• Unique IDs assigned for reference
during household survey
• Manual checking to map if
discrepancies found in data
• All household members accounted
for along with data on age, sex,
relationship to head of household,
and languages spoken
7
Honduras, May 2017

Household Survey
• Household characteristics
• Expenditure and health expenditure
• Health service utilization (women and
children)
• Family planning, reproductive history
• Child health, breastfeeding, immunization
• Physical measurements
o Weight, height, hemoglobin
• Dried blood spots (DBS) in Chiapas
• Water quality in Panama
Honduras, May 2017

Health Facility Survey
• Questionnaire administered to facility
manager
• Physical observation
o Equipment and inputs
o Pharmaceuticals
o Review of registries to detect stock outs
o Posters and health promotion materials
• Medical record review
o Record quota according to characteristics
of health unit
─ Antenatal and postnatal care
─ Deliveries
─ Maternal and neonatal complications
─ Child growth and development, deworming
Nicaragua, May 2017

Data Quality Control
• Fact finding visits to refine and
adapt surveys as needed
• IHME staff remained in field
following training and piloting in
order to launch data collection
• Return supervision visits mid-data
collection
• Continuous communication with field
teams and real-time data verification
• Weekly IHME review of indicator
performance and subcomponents
• Every census segment approved by
faculty before household survey
begins 10
Nicaragua fact finding, May 2017

Outline
• Introduction
• SMI 36-Month Challenges
11

SMI 36-Month Challenges
• Sample size and confidence interval
• Increased disparities
• Unrest and no trust in government
• Economic hardship
• Some indicators redefined after the baseline to align with
country norms, clinical best practices, and to better measure
an indicator.
12

Align with norm: fundal height only measured for ANC visit if
gestational age is >=14 weeks in El Salvador
• In the first round of MRR measurement in El Salvador, the recording
of fundal height was required at all ANC visits to pass the indicator for
ANC with quality.
• However, it was determined that fundal height was only supposed to
be checked at visits where the woman was >=14 weeks gestation and
thus the indicator definition needed to be revised.
• To account for this change in definition, we recomputed the indicator
value using this new restriction on the previously collected data.
• By removing this requirement to align with the norm, the value
increases by 8.2% for the MRR baseline and increases by 8.8% for
the follow-up.
13

Clinical best practice: updated laboratory tests/ medicines
required for appropriate management of complications
• The original neonatal complications baseline survey in Guatemala did
not capture all exams and checkups that are necessary to manage
asphyxia, including APGAR score, heart rate, and many types of
oxygen and heat application.
• After review, the definitions and surveys were updated and medical
records were recollected for the baseline time period.
• For example, now oxygen and heat should only be applied if the
APGAR score at 5 minutes is <=3, and heart rate is used as an
alternative to the pulse.
• Instead of only 46.7% of medical records passing the original indicator,
85% are now passing the recollected baseline records because the
definition was better tailored to the complication.
14

Better measure it: name or signature did not allow us to know
if a doctor provided care or not.
• The Belize MRR indicator for immediate postnatal care required a
checkup by the appropriate personnel (doctor/nurse/midwife) at
baseline in order to pass.
• After review, it was determined that it isn’t always possible to know who
cared for the neonate through the medical record documentation.
• Thus, this indicator component was removed and increased the original
baseline value by 2.3%. By removing this requirement from the second
follow-up definition, the value increases by 8.8%.
15

Recollection of Baseline Medical Records
• Some challenges
encountered to access
records from full baseline
time period
• Some changes in record
numbering systems that
made it difficult to sample
• Amount of files meant 5 years
storage and rest to
warehouses

Recollection of baseline medical records

• Lower response rate
• Folks moving to safer areas
• Active files and those with complications are available
• Not able to post-stratify for movement and timeframe of baseline
meant our results for baseline are overestimates and results for
36-month are underestimated
18

Outline
• Introduction
• SMI 36-month Challenges
19

Sample description – Households
Baseline # HH 36-month # HH
Intervention Comparison Intervention Comparison
Honduras 1,540 1,458 1,683 756
El Salvador 3,625 n/a 1,029 n/a
Nicaragua 1,300 770 1,853 774
Belize* 351 n/a 434 n/a
Mexico 3867 1543 1703 760
Guatemala 3533 872 1896 750
Panama 2195 n/a 1538 n/a
Costa Rica** 41 n/a 62 n/a
Total 16,060 4,643 9,702 3,040
*Lot Quality Assurance Sampling instead of census and household survey; number of women respondents
listed (not included in total row of households) ** Schools (not included in total row of households)
20

Sample description – Health Facilities
21
Baseline 18-month 36-month
Intervention Comparison Intervention Intervention Comparison
Honduras 59 31 60 60 30
El Salvador 65 n/a 60 60 n/a
Nicaragua 40 24 60 60 30
Belize 39 n/a 38 20 n/a
Mexico 60 30 60 60 30
Guatemala 64 29 60 61 30
Panama 38 n/a 39 39 n/a
Costa Rica n/a n/a 60 n/a n/a
Total 365 114 437 360 120

Sample description – Medical Records
22
Baseline 18-month 36-month
Intervention Comparison Intervention Intervention Comparison
Honduras 1523 940 1517 1381 894
El Salvador n/a n/a 1591 2232 n/a
Nicaragua 1255 487 1698 1704 764
Belize 1042 n/a 1190 1215 n/a
Mexico 1975 981 1999 1897 677
Guatemala 1387 457 2314 2142 1020
Panama 980 n/a 863 1199 n/a
Costa Rica n/a n/a 1518 n/a n/a
Total 8,162 2,865 12,690 11,770 3,355

36-month performance summary
Pass/Fail Improvement
Honduras Pass Yes
Belize Pass Yes
El Salvador Pass Yes
Costa Rica Fail ??
Guatemala Fail ??
Nicaragua Pass Yes
Panama Fail No
Chiapas, Mexico Pass $$$

Honduras Performance Indicator Results
1 The baseline only captured fetal heart rate, fetal movement, and uterine height at the first visit if at the appropriate gestational age. RPR was not captured at baseline as an alternative
to VDRL lab test. The original baseline value was 23.7%. To ensure comparability across rounds, the baseline estimate was recalculated to 23.2%.
2 The original baseline value was 51.1%. To ensure comparability across rounds, the baseline estimate was recalculated to 59.2%.
3 Baseline & first follow-up did not capture heart rate as an alternative to pulse.
4 Data from medical records from the baseline timeframe of complications were recollected during the 36-month evaluation. Indicator values and definitions have been updated
accordingly.
5 Original baseline value was 71.8%. This indicator was recalculated due to a change in the indicator definition to include any visit within 2 days rather than limited to only visits at exactly
2 days.
6 Zinc was not captured and thus the baseline cannot be calculated
Target Passing
% CI % CI % CI % CI % CI
3030
4 ANC with quality1
MRR 23.2% (16 - 32) 66.1% (60 - 72) 94.1% (91 - 97) 43.1% (30 - 57) 58.2% (47 - 69) 33.7% YES
3040
ANC within first trimester2
MRR 59.2% (50 - 68) 63.6% (57 - 70) 89.7% (86 - 93) 60.3% (47 - 73) 69.7% (58 - 80) 63.1% YES
4010
Institutional delivery
HH 68.6% (61 - 76) 84.7% (78 - 89) 69.4% (63-75) 77.9% (70-85) 76.6% YES
4030
Postpartum checkup within 7 days
HH 47% (40 - 54) 60.4% (53 - 67) 51.7% (46-58) 73.0% (61-82) 57.0% YES
4050
Immediate postpartum care for
women3
MRR 67.5% (60 - 75) 28.6% (18 - 41) 91.2% (85 - 95) 70% (59 - 79) 76.8% (70 - 83) 80% YES
4065
Partograph filled according to the
norm MRR 91.3% (84 - 96) 97.9% (93 - 100) 99.1% (95 - 100) 80% YES
4070
Neonatal complications managed
according to the norm4
MRR 10% (4 - 20) 42.9% (32 - 54) 7.8% (3 - 16) 6.3% (2 - 14) 36.9% YES
4080
Obstetric complications managed
according to the norm4 MRR 38.5% (29 - 48) 62.7% (55 - 70) 26.4% (18 - 36) 49.6% (41 - 58) 51% YES
4140
Children 0-59 months with pneumonia
follow-up within two days5
MRR 87% (80 - 92) 61.5% (53 - 70) 95.3% (91 - 98) 92.2% (83 - 97) 83.3% (73 - 91) 79.8% YES
5060
Children 0-59 months with diarrhea
treatment according to the norm6
MRR 39% (33 - 46) 95.3% (92 - 98) 68.3% (58 - 77) 50% YES
5070
Micronutrient consumption
HH 0.1% (0 - 1) 29.5% (24 - 36) 0.0% - 2.4% (1-7) 15.1% YES
Indicator short decription
Data
source Second Follow-up (2017)
Baseline (2013)
n/a
n/a
n/a
n/a
n/a
n/a
n/a
First Follow-up (2014)
#
Intervention
n/a
n/a
Baseline (2013) Second Follow-up (2017)
Comparison

Honduras Performance Indicator Results
*Intervention areas only

Honduras 3030: 4 ANC with Quality
28

Honduras 4010: Institutional delivery
29

Honduras 4010: Institutional delivery –
national versus SMI area trends
30

Honduras 5070: Micronutrient consumption
31

Honduras Conclusions
• Honduras met all 36-month performance targets
• Impressive progress in indicators in intervention areas
compared to comparison areas
• Honduran MoH very engaged this round
• Some indicators with especially promising results:
o Antenatal care coverage and with quality
o Institutional delivery
o Management of complications
o Micronutrient consumption
33

Belize Performance Indicator Results
Target Passing
% CI % CI % CI
2500 Contraception post-delivery 4.8% (0 - 24) 0% (0 - 9) 90.3% (83 - 95) 17.0% YES
3040 ANC within first trimester1
31.8% (14 - 55) 29.7% (22 - 38) 39.9% (32 - 48) 29.8% YES
4030 Postpartum care for woman within 7 days2
41.7% (26 - 59) 75.4% (64 - 85) 37.8% YES
4070 Neonatal complications3
23.7% (15 - 35) 53.5% (41 - 66) 37.5% YES
4080 Obstetric complications3
21.8% (13 - 33) 33.3% (23 - 45) 37.6% YES
4095 AMTSL (oxytocin)4
60% (32 - 84) 80% (70 - 88) 98.7% (95 - 100) 49.1% YES
4103 Immediate postpartum care for neonates5
30.2% (17 - 46) 86.8% (76 - 94) 88.7% (83 - 93) 39.4% YES
4410 Growth & development checks 69.6% (63 - 76) 37.5% YES
4420 Child services enrollment within 7 days 25.3% (17 - 36) 17.0% (11 - 24) 66.5% (59 - 73) 35.3% YES
5135 Diarrhea (0-59m) treatment 20% (1 - 72) 95.3% (91 - 98) 80.0% YES
Indicator short decription
#
Intervention
Baseline (2013) First Follow-up (2014) Second Follow-up (2017)
n/a
n/a
n/a
n/a
N/A n/a
1 The original baseline value was 22.8%. Due to redefinition of the indicator, the recalculated baseline value increased above the absolute target value. The original target
for a 7 percentage point increase from baseline was still met.
3 Data from medical records from the baseline timeframe of complications were recollected during the 36-month evaluation. Indicator values and definitions have been
updated accordingly.
5 The original baseline value was 19.4%. Due to redefinition of the indicator, the recalculated baseline value increased to 30.2%. The original target for a 20 percentage
point increase from baseline was still met.

Belize Performance Indicator Results

Belize 4103: Neonates managed according
to the norm
38
*Only measured at hospitals (N=4); each column represents one hospital

Belize 4095: Oxytocin/ uterotonic
administration following delivery
39
N % N % N %
Oxytocin was administered after birth 15 53.3 90 80 156 98.7
Other uterotonic was administered
after birth 15 6.7 90 2.2 156 1.9
Oxytocin/other uterotonic was
administered after delivery 15 60 90 80 156 98.7
Baseline First Follow-up Second Follow-up

Belize 4420: Newborn children enrolled in
child services in <=7 days after birth
40

Belize Conclusions
• Belize met all 36-month performance targets
• Impressive progress in indicators
• Some indicators with very promising results :
o Postpartum care
o Child enrollment
o Diarrhea treatment
• Even though targets were met, there is more work to do for
some indicators
o Early catchment of ANC
41

El Salvador
43
Intervention municipality

El Salvador Performance Indicator Results
Target Passing
% CI % CI % CI
1060
Children 6-23 mo with hemoglobin
measurements < 110 g/L 47.0% (44 - 50) 47.3% (36 - 59) 36.5% YES
2010
Current use of modern Family Planning
Method 53.9% (51 - 57) 75.0% (70-79) 60.5% YES
3030
4 ANC with Quality3
51.4% (44 - 59) 63.9% (58 - 70) 62.5% YES
3041
ANC within first trimester4
58.7% (51 - 66) 74.6% (69 - 79) 74.9% YES
4010
Most recent birth in last 2 years in-facility
and attended by SBA 85.7% (82 - 88) 98.3% (96 - 99) 94.2% YES
4031
Postpartum checkup one week after
delivery5 81.2% (78 - 84) 62.6% (53 - 71) 91.6% NO
5025
Children 12-23 months vaccinated for
MMR according to vaccination card 65.5% (61 - 70) 91.1% (83 - 95) 73.6% YES
5030
Children 12-59 mo who received 2
deworming doses in past year 36.2% (33 - 39) 40.5% (35 - 46) 56.4% NO
5060
Mothers who gave their children ORS and
zinc during last episode of diarrhea 4.5% (3 - 7) 33.7% (21 - 49) 24.4% YES
8380
Completed birth plan at an Ecos facility6
86.3% (82 - 90) 70% YES
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
n/a
# Indicator short decription
Intervention
Baseline (2011)1
First Follow-up (2014)2
Second Follow-up (2017)
1 Baseline weights have been recomputed in accordance with updated methodology.
2 Medical records were not reviewed during baseline data collection. Medical record review results from the first follow-up measurements
serve as a baseline for El Salvador.
3 Referral to another facility for ANC care was not captured in the record at the first follow-up
4 Reported gestational age was used at the second follow-up, while calculated gestational age was used at the first follow-up
5 At baseline, women were asked one question regarding postpartum checkup one week after delivery; at the second follow-up, women were
asked to report on every postpartum checkup they received in the first six weeks after delivery. The indicator calculation at second follow-up
incorporated responses from these additional questions for compliance of postpartum check.
6 Indicator was only measured at second follow-up.

El Salvador Performance Indicator Results

El Salvador 5025: MMR Vaccine
46

El Salvador 5060: Diarrhea treatment
47

El Salvador 3030: 4 ANC with Quality
49

El Salvador 4031: Postpartum care
50

El Salvador 4010: Institutional delivery –
national versus SMI area trends
51

El Salvador Conclusions
• El Salvador met 8/10 of the 36-month performance targets
• Impressive progress in most indicators
• Some indicators with very promising results:
o Timely prenatal care
o Institutional delivery with qualified personnel
o Use of family planning methods
o Treatment of diarrhea with ORS / zinc
• There is more work to do for some indicators
o Postpartum care coverage
o Anti-parasitic treatment
o Reduction of anemia
52

Costa Rica Performance Indicator Results
* 7 additional indicators not measured by IHME

Costa Rica sample: breakdown by grade
56
n % n %
7th grade 241 26.1 461 21.8
8th grade 220 23.8 458 21.6
9th grade 217 23.5 398 18.8
10th grade 203 22 415 19.6
11th grade 43 4.7 387 18.3
Total 924 2119
Baseline 2013 Second Follow-Up 2018

Indicator 8: Knowledge of correct use of modern
contraception methods
Sexually active students
N % SE N % SE
Sexually active students 237 11.6 3.3 570 26.6 4.3
7th grade sexually active 33 0 - 45 4.9 4.9
8th grade sexually active 50 2.2 1.9 74 32.6 6.4
9th grade sexually active 70 21.9 13 108 30.9 11.1
10th grade sexually active 69 5.2 2.7 159 20 4.9
Not sexually active students
N % SE N % SE
NOT sexually active students 648 2.4 0.7 1348 8.1 2.1
7th grade NOT sexually active 194 1.2 0.9 344 5.3 2.5
10th grade NOT sexually active 132 8 3.4 224 10.3 3.8
11th grade NOT sexually active 25 7 5.6 179 13.5 5.4
Second Follow-Up 2018
Baseline 2013
57

Indicator 9: Requested and received contraception at
an EBAIS, if student noted having attended an EBAIS
Sexually active students
N % SE N % SE
Sexually active students 41 92.5 5.2 166 94.6 2.2
9th grade sexually active 10 93.4 6.1 33 100 -
Not sexually active students
N % SE N % SE
NOT sexually active students 25 47.4 19.3 104 70.6 8
7th grade NOT sexually active 6 6.2 6.5 31 60 14.1
10th grade NOT sexually active 5 57 23.2 18 87 9.3
11th grade NOT sexually active 0 - - 20 62.1 11
Baseline 2013
58

Indicator 10: Current use of modern contraception by
sexually active student or partner, among students
who reported being sexually active in the past 6
months
59
N % SE N % SE
Sexually active students 162 74 7.4 361 71.6 3.8
7th grade sexually active 22 91 7.6 21 61.1 12.9
9th grade sexually active 43 70 15.9 68 78.8 8.4
11th grade sexually active 10 82.6 13.6 129 82 5.6
Baseline 2013

Costa Rica Conclusions
• Costa Rica met 1/3 of the IHME measured performance
targets
• Despite not meeting targets, progress seen especially in
knowledge and receipt of contraception methods
• More work to do to improve use of contraceptives
60

Guatemala Performance Indicator Results
1MRR indicators 4050, 4070 & 4080 displayed above for the second follow-up include records from only a 20 month time period after interventions were completed.
If the medical record time frame was extended to a 2 year time period (24 months), the values for the second follow-up intervention facilities would be the following:
4050: 40.6%, 4070: 7.2%, 4080: 21.0%.
2Definition redefined for 36-months
3Indicator excludes caesarean sections and deliveries outside of Guatemala; this baseline indicator recalculation changed the original target from 56.1% to 58.6%
Target Passing
% LB UB % LB UB % LB UB % LB UB
2080
Women who have received FP information from
a community health worker (partnered only)
HH
17.6% 14.8% 20.7% 16.7% 13.7% 20.2% 22.8% 16.8% 30.2% 21.8% 15.0% 30.5% 32.4% FAIL
4015
Women who delivered in a CAP, CAIMI, or
hospital [no skilled attendant criterion] for most
recent birth in the last two years
HH
19.3% 15.7% 23.5% 27.0% 21.7% 33.1% 29.5% 21.2% 39.6% 25.4% 17.7% 35.0% 23.7% PASS
4050
4 postpartum checks in the first hour after birth,
and 2 postpartum checks in the second hour
after birth1
MRR
13.0% 8.3% 19.2% 37.1% 30.6% 44.1% 25.5% 13.9% 40.3% 29.2% 21.2% 38.2% 28.0% PASS
4070
Management of neonatal complications
according to the norm1 MRR
13.7% 8.2% 21.0% 9.5% 5.6% 14.8% 14.3% 5.4% 28.5% 5.8% 1.9% 13.0% 16.0% FAIL
4080
Management of obstetric complications
according to the norm
1 MRR
14.5% 9.1% 21.5% 21.8% 16.0% 28.6% 23.3% 11.8% 38.6% 25.3% 16.2% 36.4% 27.4% PASS
4100
Neonatal postpartum care within 48 hours after
birth, in-facility with doctor, nurse, or auxiliary
nurse
HH
8.6% 6.8% 10.7% 19.9% 15.6% 25.1% 13.7% 8.7% 20.9% 21.4% 16.2% 27.7% 13.6% PASS
4660
Births attended to in CAPs and CAIMIs that
followed best practices2 MRR
50.0% 37.6% 62.4% 96.6% 92.3% 98.9% 44.7% 28.6% 61.7% 88.7% 77.0% 95.7% 70.0% PASS
4670
Women whose institutional birth (CAP, CAIMI,
or hospital) met at least two of five identified
standards for cultural sensitivity3
HH
38.6% 30.7% 47.1% 49.4% 39.5% 59.2% 44.5% 33.0% 56.6% 56.6% 40.6% 71.4% 58.6% PASS
5060 Treatment of diarrhea with ORS and zinc HH 0.4% 0.1% 1.7% 9.3% 5.7% 14.6% 3.2% 0.9% 10.8% 14.7% 6.7% 29.3% 10.4% PASS
5070
Children who have received 60 packets of
micronutrients in the past 6 months2 HH
1.5% 0.9% 2.5% 6.0% 3.6% 9.8% 5.2% 3.3% 7.9% 4.0% 1.9% 8.4% 37.5% FAIL
Comparison
# Indicator short description
Data
source
Intervention
36M

Guatemala Performance Indicators
64
17.6
19.3
13.0 13.7 14.5
8.6
50.0
38.6
0.4 1.5
39.8
50.4
16.7
27.0
37.1
9.5
21.8
19.9
96.6
49.4
9.3
6.0
0
10
20
30
40
50
60
70
80
90
100
2080 4015 4050 4070 4080 4100 4660 4670 5060 5070
%
passing
the
indicator
Performance Indicators
Baseline 1st Follow-up 2nd Follow-up

Guatemala 4015: In-Facility Delivery
19.3
21.7
19.2
27.0
29.9
26.6
0
10
20
30
40
50
60
70
80
90
100
Delivered in facility (CAP, CAIMI,
hospital)
Delivered withskilledattendant Delivered in facility witha skilled
attendant
%
of
women
Indicator 4015: Institutional delivery, most recent birth in last two
years
Baseline Second follow-up
65

Guatemala 4670: Culturally sensitive delivery
34.8
38.6 38.6
41.7
49.1 49.4
0
10
20
30
40
50
60
70
80
90
100
2 attributes of cultural pertinence met 2 attributes met, excluding C-section
births
2 attributes met, excluding C-section
births and births in Mexico
%
of
women
Indicator 4670: Culturally sensitive delivery, most recent birth in
last two years
66

Guatemala 4100: Skilled neonatal postpartum
care within 48 hours of birth
15.8
10.3 12.5
8.6
39.2
22.7
28.4
19.9
0
10
20
30
40
50
60
70
80
90
100
Any postnatal check infirst
week
Skilled postnatal check in-
facility within 7 days
Skilled postnatal check, eldest
children only
Skilled in-facility check within
48 hours
%
of
women
Indicator 4100: Skilled neonatal postpartum care within 48 hours of
birth
67

Guatemala 5070: Receiving micronutrients
20.8 19.2
1.5
37.6
35.1
6
0
10
20
30
40
50
60
70
80
90
100
Received any doses Consumed any doses Received at least 60 doses
%
of
children
Indicator 5070: Children who have received 60 packets of micronutrients
in past 6 months
68

Guatemala 4050: Immediate maternal PPC
Intervention
Guatemala - Baseline
All appropriate blood pressure checks
All appropriate temperature checks
All appropriate heart rate/pulse checks*
I4050
* Heart rate not captured as pulse alternative at baseline
Guatemala - Second Follow-up
All appropriate heart rate/pulse checks
I4050
Comparison
Guatemala - Baseline
All appropriate heart rate/pulse checks*
I4050
* Heart rate not captured as pulse alternative at baseline
Guatemala - Second Follow-up
All appropriate heart rate/pulse checks
I4050
Indicator Requirements:
Patient was checked for blood
pressure + temperature + heart
rate/pulse four times in the first
hour after delivery, twice in the
second hour, and once at
discharge
69

Guatemala 4660: delivery management
performance by municipality
Indicator Requirements: Patient
was attended by doctor / nurse /
obstetrician / midwife + administration
of oxytocin or other uterotonic +
partograph included in the medical
record + cord clamping occurs
between 2-3 minutes after delivery
**Value over municipality represents the
number of medical records evaluated 70
Baseline 2nd follow-up

Guatemala 4080: Management of
complications according to the norm
Obstetric complications
N % CI N % CI
according to the norm in the last two
years
138 14.5 (9.1 - 21.5) 179 21.8 (16 - 28.6)
Baseline Second Follow-Up
Neonatal complications
N % CI N % CI
according to the norm in the past two
years
124 13.7 (8.2 - 21.0) 179 9.5 (5.6 - 14.8)
71

Guatemala Conclusions
• Guatemala met 7/10 of the 36-month performance targets
• Despite not meeting targets, progress was observed,
especially for ANC, institutional delivery, and postpartum care
• There is more work to be done, and indicator results in general
are lower than what is observed in other SMI countries
• Challenges with medical record sampling and storage of
records
72

Nicaragua Performance Indicator Results
1 The baseline value was previously reported at 37.3%. To ensure comparability across rounds, the baseline estimate was recalculated to 39.6%. Baseline uses calculated
gestational age while follow-ups use recorded gestational age.
2 The second follow-up survey included an additional question that asked if women were checked before discharge after delivering in facility. If a women was checked before
discharge, she was considered to have passed this indicator per definition. Due to the addition of this question, the baseline and follow-up values are not strictly comparable.
3 Data from medical records from the baseline timeframe of complications were recollected during the second follow-up evaluation. Indicator values and definitions have been
updated accordingly.
4 Baseline did not capture result of the pregnancy (live or stillbirth), so records could not be excluded based on this criteria.
5 This indicator was not captured at the baseline & first follow-up evaluations.
6 The baseline value was previously reported at 47.3%. To ensure comparability across rounds, the baseline estimate was recalculated to 43.5%.

Nicaragua FP: Contraception post-delivery
75

4030: Postpartum care within 10 days
76
*Intervention areas at second follow-up only; includes check before discharge at in-facility delivery

4103: Immediate PPC for neonates in a
health facility after their birth
N % N % N %
Vitamin K 69 95.7 184 98.9 279 92.5
Application of prophylaxis with oxytetracycline
ophthalmic/chloramphenicol 69 91.3 184 98.9 279 92.1
Curing the umbilical cord with water and
chlorhexidine 69 55.1 184 96.2 279 68.8
Evaluation for the presence of malformations 69 92.8 184 93.5 279 88.9
BCG vaccine 69 75.4 184 90.2 279 88.2
APGAR score (at 1 or 5 minutes) 69 100 184 100 279 94.3
Respiratory rate 69 26.1 184 78.3 279 58.8
Weight 69 95.7 184 98.9 279 92.1
Height 69 94.2 184 92.4 279 91.4
Head circumference 69 88.4 184 91.3 279 91
Appropriate immediate postpartum care for
neonates 69 7.2 184 67.9 279 43.7
77

5025: MMR vaccine according to
vaccination card (12-23 months)
78

4070: Management of Neonatal Complications
- asphyxia
N % N %
Vital signs checked: 11 63.6 30 93.3
Heart rate/pulse 11 81.8 30 96.7
Respiratory rate 11 63.6 30 93.3
APGAR at 1 minute 11 72.7 30 96.7
APGAR at 5 minutes 11 72.7 30 96.7
Laboratory tests: 11 27.3 30 40
Glucose 11 27.3 30 40
Oxygen saturation (if severe asphyxia) 1 0 1 0
Heat application 11 36.4 30 60
Oxygen administration (if severe asphyxia) 1 0 1 0
One of the following (if severe asphyxia): 1 100 1 100
Ambu (positive pressure ventilation) 1 100 1 100
Cardiac massage 1 0 1 0
Tracheal intubation 1 0 1 0
Evaluated by a doctor 11 72.7 30 86.7
Referred to a complete facility (if severe asphyxia &
neonate did not die in the facility) 1 100 1 100
Asphyxia managed according to the norm 11 18.2 30 20
2nd Follow-up
Baseline
Basic
N % N %
Vital signs checked: 24 95.8 10 100
Heart rate/pulse 24 100 10 100
Respiratory rate 24 100 10 100
APGAR at 1 minute 24 95.8 10 100
APGAR at 5 minutes 24 95.8 10 100
Laboratory tests: 24 87.5 10 60
Glucose 24 87.5 10 60
Oxygen saturation (if severe asphyxia) 0 0
Heat application 24 70.8 10 80
Oxygen administration (if severe asphyxia) 0 0
One of the following (if severe asphyxia): 0 0
Ambu (positive pressure ventilation) 0 0
Cardiac massage 0 0
Tracheal intubation 0 0
Evaluated by a doctor 24 100 10 100
Asphyxia managed according to the norm 24 62.5 10 60
Complete
Baseline 2nd Follow-up
79

4080: Management of Maternal Complications
– hemorrhage
N % N %
Pulse/heart rate 54 92.6 114 99.1
Blood pressure 54 98.1 114 97.4
Medications administered (at least one of the following): 54 83.3 114 84.2
Ringer's Lactate/Hartmann's solution 54 70.4 114 43.9
Saline Solution 54 59.3 114 69.3
Appropriate management of specific causes of hemorrhage 32 78.1 60 65
Hemorrhage managed according to the norm 54 75.9 114 70.2
Basic
N % N %
Vital signs checked: 45 100 19 100
Pulse/heart rate 45 100 19 100
Blood pressure 45 100 19 100
Medications administered (at least one of the following): 45 93.3 19 84.2
Ringer's Lactate/Hartmann's solution 45 66.7 19 63.2
Saline Solution 45 57.8 19 63.2
Laboratory tests: 45 20 19 63.2
Hematocrit 45 88.9 19 100
Hemoglobin 45 20 19 63.2
Platelets 45 80 19 100
Appropriate management of specific causes of hemorrhage 18 94.4 12 75
Hemorrhage managed according to the norm 45 17.8 19 52.6
Complete
80

Nicaragua conclusion
• SMI shows great progress in Nicaragua
• Some indicators show promising results:
o Timely antenatal care
o Use of family planning methods
o Postpartum care with qualified personnel
• There is room to improve for some indicators:
o Deworming treatment
o Information about family planning by health facilty personnel or
community health workers
81

Panama Performance Indicator Results
1. Redefined to count women who underwent sterilization as in need of and using contraception, and women who are infertile or desire pregnancy as not in need of
contraception.
2. As at baseline definition, women who didn't know how many ANC checks they had or didn't know who attended them are counted as zero. If excluding "don't know" responses:
baseline 51.6%(CI 45.1-58), follow-up 35.9% (CI 28.7-43.7).
3. MRR indicators 3040 & 4095 displayed above for the second follow-up include records from only a 22 month time frame after interventions were completed. If the medical
record time frame was extended to a 2 year time period (24 months), the values for the second follow-up facilities would be the following: 3040: 31.3%, 4095: 85.5%. The original
3040 baseline value included doctor/nurse requirement at the first visit, but that requirement is now excluded.
4. Original baseline in performance matrix was rounded to 1%.
Target Passing
% LB UB % LB UB
2020 Unmet need for contraception
1
HH 90.0% 85.2% 93.4% 98.8% 97.6% 99.5% 84.3% FAIL
3020
4 prenatal care visits with doctor or professional
nurse
2 HH
38.3% 33.3% 43.5% 24.2% 19.2% 30.0% 53.3% FAIL
3040 First prenatal check before 13 weeks gestation
3
MRR 37.3% 29.8% 45.2% 31.2% 26.9% 35.8% 46.4% FAIL
4020
Maternal postpartum care within 48 hours after
birth, with doctor or professional nurse
HH
13.4% 10.2% 17.3% 10.9% 7.7% 15.2% 28.4% FAIL
4095 Application of oxytocin3
MRR 78.3% 71.1% 84.5% 85.4% 81.0% 89.1% 85.0% PASS
4100
Neonatal postpartum care within 48 hours after
birth, in-facility with doctor or
professional/auxiliary nurse
HH
10.8% 8.1% 14.3% 16.7% 12.3% 22.3% 20.8% PASS
5025
MMR vaccination according to card for children
12-24 months old
HH
69.1% 62.2% 75.2% 71.0% 65.7% 75.8% 76.1% FAIL
5030
Children with at least 2 deworming treatments
in the past year
HH
8.7% 6.7% 11.2% 12.9% 10.2% 16.2% 38.7% FAIL
5060 Treatment of diarrhea with ORS and zinc HH 0.6% 0.1% 4.0% 6.2% 2.2% 16.4% 20.6% FAIL
5710 Adequate water quality
4
HH 0.9% 0.1% 6.4% 0.0% 0.0% 0.0% 16.0% FAIL
Data
source 36M
Intervention

Panama Performance Indicators
85
0
10
20
30
40
50
60
70
80
90
100
2020 3020 3040 4020 4095 4100 5025 5030 5060 5710
%
meeting
the
indicator
Performance Indicators

Panama 2020: Unmet need for contraception
86
83.9
85.7
90.0
86.9
98.3 98.8
0
10
20
30
40
50
60
70
80
90
100
In needof contraception Using no method, among women in
need
Using no modern method, among
women inneed
%
of
women
Indicator 2020: Unmet need among women in need of
contraception

Panama 3020: 4 ANC visits
87
85.5
36.9
51.6
38.3
59.5
28.7
35.9
24.2
0
10
20
30
40
50
60
70
80
90
100
Any ANC visit 4 skilled ANC visits, among
primiparous women
4 skilled ANC visits, don't
know responses excluded
4 skilled ANC visits
%
of
women
Indicator 3020: 4 prenatal care visits, most recent birth in last two
years

Panama 4020: Maternal postpartum care
88
51.9
29.7
18.5
13.4
50.6
26.3
20.4
10.9
0
10
20
30
40
50
60
70
80
90
100
Any check in first 6 weeks Skilled check within 7-42
days
Skilled check within 7 days Skilled check within 48 hours
%
of
women
Indicator 4020: Maternal postpartum care within 48 hours with
qualified personnel, most recent birth in last two years

Panama 5025: MMR vaccination according to
card for children 12-24 months old
89
83.5
61.0
69.1
88.2
76.6
71.0
0
10
20
30
40
50
60
70
80
90
100
Received MMR vaccine, recall or card Received MMR vaccine, recall only Received MMR vaccine, card only
%
of
children
Indicator 5025: MMR vaccine according to card, for children 12-24
months old

Panama 5710: Adequate water quality
• Requirements:
• Positive for chlorine
• Negative for coliforms
• Zero cases tested were both
positive for chlorine and
negative for coliforms
• Shown: A test for E. Coli and
coliforms, which turns blue-
green if positive. The test on
the far left has incubated for
24 hours, and the ones in the
middle and far right have
incubated for 12 hours.
90

Culture against family planning
• Guna leaders originally vetoed the family planning survey sections.
o Consider contraception use a genocidal crime and that goes against their
population growth objectives.
o Fear of promotion of family planning as a way to reduce their population.
o Traditional line of communication established to inform pregnancy, the first
in this line is the healer before the family, therefore consider disrespectful
that a stranger comes to investigate women about pregnancy and
abortions.
o They also expressed concern that with these questions they could judge
their traditional medicine badly.
• After further explanations and discussions around these questions,
there was agreement to include these questions to provide key
information to implement services aimed at preventing maternal
and child deaths.

Feeling of marginalization
• In meeting with the Congress of the
Guna Yala Culture (June 13 & 14),
they indicated a desire to be involved
in planning of the operation.
• Road blockade of Guna people,
protesting lack of water services
(encountered during pilot)

Complaints about services
• When approached for the follow-up survey, communities complained
they had no information about the Initiative from the MoH
• In a meeting, community representatives and liaison from the MoH
were just exchanging contact data, what made evident the lack of
previous contact. This was noticed by the community
representatives.

Panama Conclusion
• A setback driven by political and cultural issues
• Requires attention to culture and efforts to reach out to
leadership and build trust
• Requires explanation of purpose of services (healthy babies
and better functional and cognitive health by prenatal care and
spacing of deliveries rather a focus on family planning)
• Need visible measures and programs to follow the
engagement immediately to show good will
• Need continuous dialogues and communication
• Provide other services besides health, such as education
• Need a qualitative study to assess the barriers and the issues
that contributed to these results in order to address them (this
is crucial). Basically we need a listening tour.
• 94

Chiapas Performance Indicator Results
1The baseline value was previously reported at 52.7%. To ensure comparability across rounds and between countries, the baseline estimate was
recalculated to 51.2%.
2The baseline calculation for indicator 4010 only includes doctor and professional nurse as skilled personnel, because professional midwife was not
asked.
3The baseline value was previously reported at 48.5%. To ensure comparability across rounds and between countries, the baseline estimate was
recalculated to 48.9%.
Target Passing
% LB UB % N LB UB % LB UB % LB UB
2020
Women in need of FP who are not
using form of contraception1 HH
51.2% 46.9% 55.6% 53.0% 45.7% 60.1% 36.9% 31.1% 43.2% 44.0% 35.1% 53.2% 45.7% PASS
3035
5 ANC visits with qualified personnel
and according to norms
MRR
6.8% 2.3% 15.3% 12.9% 10.0% 16.3% 0.0% 0.0% 16.1% 7.0% 3.3% 12.9% 16.8% FAIL
4010
Institutional birth with qualified
personnel
2 HH
34.7% 29.5% 40.4% 40.5% 31.4% 50.3% 59.7% 48.7% 69.8% 70.8% 53.6% 83.6% 42.7% PASS
4030
Post partum care within 7 days by
qualified personnel
HH
26.2% 23.0% 29.7% 26.9% 21.1% 33.7% 33.7% 27.0% 41.0% 40.1% 33.8% 46.7% 32.2% PASS
5060 ORS administration for diarrhea HH 48.9% 42.7% 55.2% 57.6% 48.0% 66.7% 53.4% 43.8% 62.7% 62.6% 45.9% 76.7% 63.9% PASS
4050 Immediate postpartum care MRR 0.0% 0.0% 1.8% 47.8% 40.9% 54.9% 0.0% 0.0% 2.5% 10.8% 5.5% 18.5% 30.0% PASS
4090
Active management of 3rd stage of
delivery
MRR
72.3% 65.6% 78.3% 97.3% 94.3% 99.0% 62.4% 53.9% 70.4% 93.2% 86.5% 97.2% 92.3% PASS
4070
Management of neonatal
complications according to norms
MRR
22.8% 16.2% 30.5% 38.5% 31.1% 46.2% 12.5% 0.3% 52.7% 20.7% 11.2% 33.4% 20.0% PASS
4080
Management of obstetric
complications according to norms
MRR
17.9% 11.2% 26.6% 24.4% 19.0% 30.6% 21.1% 9.6% 37.3% 16.8% 10.1% 25.6% 20.0% PASS
5025
MMR vaccine according to card,
children 12-23 months3 HH
48.9% 43.1% 54.6% 49.8% 41.1% 58.5% 48.8% 39.8% 57.9% 41.3% 32.2% 51.0% 55.5% PASS
36M
Data
source
Intervention Comparison

Mexico Performance Indicators
99

4010: Institutional delivery with skilled
personnel
**The baseline calculation for indicator 4010 only includes doctor and professional
nurse as skilled personnel, because professional midwife was not asked.
100

Mexico 3035: 5 ANC visits according to the
norm
MEX I3035 - BL
At least 5 ANC visits
Weight + blood pressure checked at all visits
Fundal height checked (if gestational age >13 weeks at visit)
Fetal movement + fetal heart rate checked (if gestational age >20 weeks at visit)
Blood glucose lab test at least once
HIV lab test at least once
Hemoglobin lab test at least once
Urinalysis lab test test at least once
I3035
MEX I3035 - 18m
I3035
MEX I3035 - 36m
I3035
*HIV test not captured in all records at baseline. Fundal height + fetal checks only captured at first visit if gestational age is eligible.
101

Mexico 4050: Postpartum patients
evaluated within 2 hours after delivery
102
*Heart rate was not captured as an alternative at baseline or 1st Follow-up

Mexico 4080: Management of
complications
N % N %
Women with obstetric
complications managed
according to the norm in the last
two years 106 17.9 (11.2- 26.6) 255 24.3 (19.2- 30.1)
CI CI
N % N %
Neonates with complications
managed according to the norm
in the last two years 145 22.8 (16.2- 30.5) 190 37.4 (30.5- 44.7)
CI CI
103

5060: ORS administration
104

5025: MMR vaccine according to card
105

Measles immunization among children with DBS sample
107

Measles immunization effective coverage
• Despite MMR card coverage
showing only a minimal
increase for intervention areas,
dried blood spot analysis for
measurement of effective
coverage of the MMR vaccine
showed notable progress.
• The antibodies for children has
increased greatly, indicating
that the efforts that SMI
invested in improving the cold
chain have paid off.
• An impressive and a huge
improvement from the
baseline.
Intervention
N % N %
DBS coverage, 12 <= age < 24
(months)
716 61.2% 236 80.5%
DBS coverage among card holders,
12 <= age < 24 (months)
645 63.3% 195 82.2%
Intervention
Baseline Second Follow-up
Comparison
N % N %
DBS coverage, 12 <= age < 24
(months)
302 72.1% 94 69.4%
DBS coverage among card holders,
12 <= age < 24 (months)
276 73.9% 80 65.8%
Comparison
108

Measles immunization by card and DBS coverage
• Increase in MMR coverage in SMI intervention areas
• Decrease in MMR coverage in comparison areas
• IDB allowed SMI funds to be used to purchase vaccines and to be used
for all ages, as well as outside of the intervention areas during this time
929 716
329 236
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Card DBS
Intervention
390 302
152 94
0.0%
20.0%
40.0%
60.0%
80.0%
100.0%
Card DBS
Comparison
N shown inside bar.
109

Increase in health service utilization among
Indigenous populations
• Around 75% of the sample population was indigenous at the baseline and
second follow-up in the intervention areas.
• Increases in institutional delivery and PPC observed for the indigenous
population but did not for non-indigenous.
• Performance is much lower in indigenous women but improves significantly
compared to non-indigenous women.
N % SE N % SE N % SE N % SE
Women (age 15-49) delivered in
hospital/health center with skilled
attendant in their most recent
pregnancy in the last two years
1687 26.5 2.5 572 34.5 4.6 373 78.3 2.8 131 78.9 9.8
Women (age 15-49) who received
postpartum care within 7 days with
skilled personnel (doctor, nurse, or
pro. midwife) in their most recent
pregnancy in the last two years
1682 22.7 1.8 573 26.1 3.5 373 45 3 132 32.1 5.2
INTERVENTION - INDIGENOUS INTERVENTION - NONINDIGENOUS
Baseline (2013) Follow-up (2018) Baseline (2013) Follow-up (2018)
110

Increase in health service utilization among
Indigenous populations
111
N % SE N % SE N % SE N % SE
Sought care for recent illness 983 54.6 2.7 360 65.5 2.8 262 62.4 3.4 101 67 3.9
Child was hospitalized for recent
illness
237 1.2 0.7 97 5.3 2.1 73 15 6.3 44 4 2.6
Sought care for suspected acute
respiratory infection
1086 50.5 2.6 434 57.9 3.2 291 56.2 4.5 98 52 4.9
Sought care for diarrhea 415 55.3 3.8 166 62.7 3.5 99 49.9 5.7 59 54 5.2
INTERVENTION - INDIGENOUS INTERVENTION - NONINDIGENOUS
Baseline (2013) Follow-up (2018) Baseline (2013) Follow-up (2018)
• The indigenous population increased child care seeking behaviors for all of
these, with the greatest improvement in seeking care for a recent illness
(10.9% increase).
• The nonindigenous population decreased in their care seeking behaviors
except for any recent illness, where there was only a 4.6% increase.

Cultural barriers to use of family planning
112
% LB UB % LB UB % LB UB % LB UB
Women in need of FP
who are not using form
of contraception 51.2% 46.9% 55.6% 53.0% 45.7% 60.1% 36.9% 31.1% 43.2% 44.0% 35.1% 53.2%
COMPARISON
Baseline (2013) Second Follow-up (2018) Baseline (2013) Second Follow-up (2018)
INTERVENTION
• Based on our work in the SMI Process Evaluation, we found, especially in
rural areas, that there are many misconceptions about risks and side effects
of contraceptives, as well as religious objections and cultural barriers to
accepting family planning methods.
• Despite these challenges, the unmet need for contraception in intervention
areas only increased by 1.8%, while the comparison area increased by
7.1%. With these major challenges, maintaining contraceptive use is an
achievement rather than allowing the gap to increase greatly for unmet
need.

Difference-in-difference analysis in percent of
healthcare out of household expenditure
• Percent of
healthcare out of
household
expenditure
increased by 4.2%
in comparison but
decreased by 4.1%
in intervention areas
• SMI effect is 0.62
Healthcare
expenditure
%
of
household
expenditure
Comparison at follow-up
Comparison at baseline
Intervention at baseline
Intervention at follow-up
Area*Rounds
Least Squares Means Estimate
Effect Label Estimate Standard Error z Value Pr > |z|
Area*Rounds Diff in Diff -0.6246 0.1223 -5.11 <.0001

Chiapas Conclusion
• Chiapas met 9/10 of the 36-month performance indicator
targets
• Despite wide confidence intervals, statistically significant
progress observed in key areas
• Strongly believe SMI has influenced hard to reach areas in the
intervention regions and indigenous communities.
• It is clear that the program is working and is having success in
these areas.
• Reaching an effective coverage over 80% in this time frame is
an outstanding achievement.
• Increased MMR coverage is a success
114

Outline
• Introduction
• SMI 36-month Challenges
115

Conclusions and Future Activities
• Signs of large improvements in countries except for Panama
and Guatemala
• Reasons for failures are outside the Initiative mandate (i.e.
political and economical factors with mistrust of the
Government)
• Findings raise concerns about sustainability on the long run
• On the other hand, impact of the evaluation is apparent in
control areas and even in other parts of the countries
(Nicaragua expansion and Mexico DBS)
• Impact on health facilities is very visible
• Supplies are still a concern (vaccine shortage in Mexico and
lack of proper distributions)
116

• Should we continue or not?
• Yes with some changes
• Panama:
o Engage the community with a focus on health education.
o Water quality should be addressed
o Focus on family planning and the role of vaccines (MCH focus)
• Belize, Honduras, El Salvador, and Nicaragua:
o Maintain same level
o Change the targets
o Use one sided test
117

• Guatemala and Costa Rica:
o Reduce engagement
o Change targets (higher targets)
o One sided test
o Reduced quantitative evaluation
o More qualitative approach (why, what are the barriers, what
should be prioritized, switch to DBS, and use the failure to
energize the counterparts)
118

• Mexico:
o Maintain same level
o Change the targets
o Use one sided test
o Include access to warehouses/storage and distribution of supplies
in the evaluation
o Maintain pressure on effective coverage
o Qualitative evaluation to answer why supplies are a challenge and
what locals could do to improve the situation (role of Chiapas vs.
MOH)
o Cross-country learnings between indigenous experiences with
SMI, for example between Mexico and Panama
119

• Should we continue or not?
• Time for a health summit to discuss the road ahead.
o Invite all players (health, education, finance, etc…)
o Share lessons of success and failures
o Discuss challenges and opportunities
o Involve academia
o Use SDGs and HCI as a motivator
o Power of incentives (awards for best performers and most
improved municipalities)
120

Ali H. Mokdad, PhD
mokdaa@uw.edu
Thank you!

Costa Rica 10: Methods of pregnancy
prevention
N % N %
Did not use modern contraception 162 26 361 28.4
Used modern contraception 162 74 361 71.6
Condom 123 72.9 270 72.8
Implant* 123 0 270 13.8
Contraceptive pills 123 13.8 270 5.4
IUD* - - 270 4
Injection, patch, or vaginal ring 123 6.7 270 2.3
* At baseline, Implant and IUD were combined. They were separated into two options during the follow-up survey.
** Responses for non-modern methods of contraception (e.g. ejaculation outside the vagina) removed from
table
123

Guatemala 4050:
Immediate maternal postpartum care
Denominator:
Total number of postpartum care records from basic and complete facilities in the last
two years
Formula:
Patient was checked for blood pressure + temperature + heart rate/pulse four times in
the first hour after delivery, twice in the second hour, and once at discharge
N % CI N % CI N % CI
Postpartum patients who
were evaluated appropriately
during the first two hours
after birth
161 13 (8.3 - 19.2) 266 39.8 (33.9 - 46) 210 37.1 (30.6 - 44.1)
Baseline 1st Follow-up 2nd Follow-Up
124

Guatemala 4660: Delivery management
Denominator:
Total number of delivery records in the sample from CAPs and CAIMIs in the last year
Formula:
Patient was attended by doctor / nurse / obstetrician / midwife + administration of oxytocin or other
uterotonic + partograph included in the medical record + cord clamping occurs between 2-3 minutes
after delivery
Note: At baseline and first follow-up, cord clamping time was defined as 90 seconds.
N % CI N % CI N % CI
Delivery managed according to
the norm
68 50 (37.6 - 62.4) 127 50.4 (41.4 - 59.4) 148 96.6 (92.3 - 98.9)
* At baseline and first follow-up, cord clamping time is defined as 90 seconds.
Baseline 1st Follow-up 2nd Follow-Up
125

Guatemala 4080: Management of maternal
complications
N % CI N % CI
according to the norm in the last two
years
138 14.5 (9.1 - 21.5) 179 21.8 (16 - 28.6)
N % CI N % CI
Sepsis 5 40 (5.3 - 85.3) 5 60 (14.7 - 94.7)
Hemorrhage 69 26.1 (16.3 - 38.1) 100 37 (27.6 - 47.2)
Severe pre-eclampsia 54 0 (0 - 6.6) 64 0 (0 - 5.6)
Eclampsia 10 0 (0 - 30.8) 11 0 (0 - 28.5)
Total 138 14.5 (9.1 - 21.5) 179 21.8 (16 - 28.6)
126

Guatemala 4070: Management of neonatal
complications
N % CI N % CI
according to the norm in the past two
years
124 13.7 (8.2 - 21.0) 179 9.5 (5.6 - 14.8)
N % CI N % CI
Sepsis 53 0 (0 - 6.7) 62 3.2 (0.4 - 11.2)
Asphyxia 27 63 (42.4 - 80.6) 16 31.2 (11 - 58.7)
Low birth weight 31 3.2 (0.1 - 16.7) 70 15.7 (8.1 - 26.4)
Prematurity 20 0 (0 - 16.8) 52 5.8 (1.2 - 15.9)
Total 124 13.7 (8.2 - 21.0) 179 9.5 (5.6 - 14.8)
127

Guatemala 4080:
128
*Value over municipality represents the number of medical records evaluated

Guatemala 4070:
129
*Value over municipality represents the number of medical records evaluated

3040: ANC <= 12 weeks gestation
Gestational age (weeks)
Baseline
18-months
36-months
130

FPI: Family Planning Information
*Intervention areas only at 36-months
131

4030: Postpartum care within 10 days
132
*Intervention areas at second follow-up only; includes check before discharge at in-facility delivery

133

134

4080: Management of Maternal
Complications
N % N % N % N %
Management of severe pre-eclampsia 25 12 69 17.4 39 12.8 47 0
Management of eclampsia 2 0 6 33.3 5 0 5 0
Management of hemorrhage 54 75.9 114 70.2 45 17.8 19 52.6
Management of sepsis 17 76.5 34 82.4 10 50 8 37.5
Baseline 36-month Baseline 36-month
Basic Complete
135

4103: Neonatal care
NIC Immediate PPC - BL
Apgar score (at 1 or 5 minutes)
Respiratory rate
Weight
Height/length
Head circumference
Evaluation for the presence of malformations
BCG vaccination
Cured the umbilical cord with water & chlorhexidine
Oxytetracycline ophthalmic prophylaxis or chloramphenicol administration
Vitamin K administration
I4103
NIC Immediate PPC - 18m
Respiratory rate
Weight
Height/length
Head circumference
BCG vaccination
I4103
NIC Immediate PPC- 36m
Respiratory rate
Weight
Height/length
Head circumference
BCG vaccination
I4103
136

Nicaragua 5030: Deworming treatment
137

Nicaragua 5030: Deworming treatment
138

4080: Management of Maternal
Complications – severe pre-eclampsia
N % N %
Vital signs checked: 25 96 69 95.7
Blood pressure 25 100 69 97.1
Pulse/heart rate 25 100 69 97.1
Respiratory rate 25 96 69 97.1
Laboratory test: Urine Protein 25 60 69 62.3
Medication Administered: 25 52 69 59.4
Magnesium Sulfate 25 52 69 62.3
Hydralazine/Labetalol/Nifedipine if bp > 110 4 100 10 70
Transferred to a complete facility 25 28 69 26.1
Pre-eclampsia managed according to the norm 25 12 69 17.4
Basic
N % N %
Blood pressure 39 100 47 100
Pulse/heart rate 39 100 47 100
Respiratory rate 39 100 47 97.9
Patellar reflex 39 69.2 47 53.2
Laboratory tests 39 15.4 47 14.9
Platelet count 39 89.7 47 91.5
Urine protein 39 82.1 47 74.5
Creatinine 39 66.7 47 76.6
Uric acid 39 43.6 47 44.7
Aspartate aminotransferase/Glutamic Transaminase
Oxalacetic (GOT) 39 79.5 47 68.1
Alanine transaminase/Glutamic transaminase pyruvic
(GPT) 39 76.9 47 68.1
Lactate dehydrogenase 39 30.8 47 46.8
Medication Administered: 39 87.2 47 57.4
Magnesium Sulfate 39 87.2 47 57.4
Hydralazine/Labelatol/Nifedipine (if diastolic blood
pressure > 110) 14 100 6 100
Pre-eclampsia managed according to the norm 39 12.8 47 0
Complete
139

Panama 5060: ORS and zinc administration
140
57
1.2 0.6
73.7
6.4 6.2
0
10
20
30
40
50
60
70
80
90
100
Received any ORS Received zinc Received zinc and ORS
%
of
children
Indicator 5060: Oral rehydration solution and zinc
administration

Panama 4100: Neonatal postpartum care
141
66.5
17.2
11.5 10.8
63.7
21.8
16.7 16.7
0
10
20
30
40
50
60
70
80
90
100
Any check Skilled check within 48 hours,
among only children
Skilled check within 48 hours Skilled in-facility check within
48 hours
%
of
women Indicator 4100: Neonatal postpartum care within 48 hours with
qualified personnel, most recent birth in last two years

2020: Unmet need for contraception among
women in need

Chiapas 2020: Unmet need for
contraception among women in need
143

Chiapas 4010: Institutional delivery with
skilled personnel
144

Chiapas 4030: skilled postpartum within 7
days
145

Chiapas 5060: ORS administration
146

Chiapas 5025: MMR vaccine according to
card
147

Chiapas 4030: skilled postpartum within 7
days
148

Mexico 3035: 5 ANC visits according to the
norm
Denominator:
Total number of antenatal care records from ambulatory facilities.
Formula:
Ambulatory: Observe the following in the record: woman had at least 5 ANC visits +
physical checkups performed at each visit (weight + blood pressure + uterine height (if
gestational age >13 weeks) + fetal heart rate (if gestational age >20 weeks) + fetal
movement (if gestational age >20 weeks)). Lab tests performed at least once: blood
glucose level + HIV test + Hb level + urinalysis.
N % N % N %
Women of a reproductive age
who received the minimum
required number of ANC care
according to best practices for a
birth in the last two years 73 6.8 (2.3- 15.3) 321 12.5 (9.1- 16.6) 457 12.9 (10.0- 16.3)
2nd Follow-up
CI CI CI
Baseline 1st Follow-up
*At the baseline, fetal heart rate + fetal movements + fundal height were only measured at the first visit if the woman was of the appropriate
gestational age. HIV laboratory test not captured in all facilities at the baseline.
149

Mexico 4050: Results
150
*Heart rate was not captured as an alternative at baseline or 1st Follow-up

Mexico 4090: Active management of 3rd
stage of labor
Denominator:
Total number of delivery records at basic and complete facilities in the sample.
Exclude deliveries that did not occur inside the facility.
Formula:
Woman was administered oxytocin/other uterotonic after delivery.
N % N % N %
Oxytocin/other uterotonic was
administered 202 72.3 (65.6- 78.3) 336 83.6 (79.2- 87.4) 254 97.2 (94.4- 98.9)
CI CI CI
151

Mexico 4080: Management of
complications by complication type
N % SE N % SE
Hemorrhage 65 23.1 5.2 91 50.5 5.2
Severe pre-eclampsia 37 8.1 4.5 150 8.7 2.3
Eclampsia 3 0 12 16.7 10.8
Sepsis 7 71.4 17.1 6 50 20.4
Total 106 17.9 3.7 255 24.3 2.7
N % SE N % SE
Low birth weight 31 25.8 7.9 78 47.4 5.7
Prematurity 33 15.2 6.2 41 19.5 6.2
Asphyxia 47 70.2 6.7 41 73.2 6.9
Sepsis 88 13.6 3.7 86 30.2 5
Total 145 22.8 3.5 190 37.4 3.5
152

SMI 36-Month Results: Honduras Performance Indicator Results Pass Targets

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SMI 36-Month Results: Honduras Performance Indicator Results Pass Targets