Table 4.
Validation results for indicators*
| Indicator | Total number | Observer prevalence (%) | Sensitivity (95% CI) | Specificity (95% CI) | Self–report survey estimate (%), based on sensitivity and specificity | AUC (95% CI) | IF | High accuracy (AUC>0.70) & low bias (IF 0.75–1.25) |
|---|---|---|---|---|---|---|---|---|
|
Initial client assessment: | ||||||||
| Woman referred to facility because of a problem |
655 |
7.9 |
25.0 (14.0–38.9) |
93.2 (90.9–95.1) |
8.2 |
0.59 (0.55–0.62) |
1.04 |
IF |
| Provider washes hands with soap and water or uses antiseptic before initial examination |
467 |
26.6 |
83.9 (76.2–89.9) |
32.9 (28.0–38.2) |
71.5 |
0.58 (0.54–0.63) |
2.69 |
|
| Takes blood pressure |
654 |
87.0 |
87.7 (84.9–90.2) |
23.3 (11.8–38.6) |
86.3 |
0.55 (0.52–0.59) |
0.99 |
IF |
|
Provider respectful care: | ||||||||
| Woman allowed to drink liquids or eat |
624 |
42.0 |
72.5 (66.7–77.8) |
37.3 (32.3–42.5) |
66.8 |
0.55 (0.51–0.59) |
1.59 |
|
| Encourages/assists woman to ambulate during labor |
644 |
77.5 |
90.2 (87.2–92.6) |
24.1 (17.4–31.9) |
87.0 |
0.57 (0.53–0.61) |
1.12 |
IF |
| Encourages/assists woman to assume different positions in labor |
649 |
58.2 |
19.1 (15.2–23.4) |
92.3 (88.4–95.1) |
14.3 |
0.56 (0.52–0.59) |
0.25 |
|
| Woman allowed to have a support person during labor and delivery |
648 |
9.1 |
23.7 (13.6–36.6) |
92.7 (90.3–94.7) |
8.8 |
0.58 (0.54–0.62) |
0.97 |
IF |
| Support companion present during birth |
644 |
4.8 |
48.4 (30.2–66.9) |
98.5 (97.2–99.3) |
3.7 |
0.73 (0.70–0.77) |
0.77 |
Both |
|
First stage of labor: | ||||||||
| Induces labor with uterotonic |
630 |
4.6 |
69.0 (49.2–84.7) |
92.0 (89.6–94.1) |
10.8 |
0.80 (0.77–0.84) |
2.35 |
AUC |
| Augments labor with uterotonic |
625 |
22.4 |
72.9 (64.7–80.0) |
70.5 (66.2–74.5) |
39.2 |
0.72 (0.68–0.75) |
1.75 |
AUC |
| Uterotonic received (labor induction or augmentation) |
619 |
27.1 |
78.0 (70.9–84.0) |
69.0 (64.5–73.2) |
43.8 |
0.73 (0.70–0.77) |
1.61 |
AUC |
| Membranes ruptured (labor induction or augmentation) |
650 |
42.3 |
4.0 (2.0–7.0) |
97.6 (95.5–98.9) |
3.1 |
0.51 (0.47–0.55) |
0.07 |
|
|
Skilled birth attendance: | ||||||||
| Skilled main provider† labor |
649 |
92.6 |
90.5 (87.9–92.7) |
16.7 (7.5–30.2) |
90.0 |
0.54 (0.50–0.58) |
0.97 |
IF |
| –Main provider labor nurse/midwife |
649 |
92.1 |
81.1 (77.7–84.2) |
27.5 (15.9–41.7) |
80.4 |
0.54 (0.50–0.58) |
0.87 |
IF |
| Skilled main provider† delivery |
644 |
92.9 |
95.0 (92.9–96.6) |
15.2 (6.3–28.9) |
94.3 |
0.55 (0.51–0.59) |
1.02 |
IF |
| –Main provider delivery doctor (ob–gyn)/medical resident |
644 |
11.8 |
82.9 (72.5–90.6) |
89.3 (86.4–91.7) |
19.3 |
0.86 (0.83–0.89) |
1.63 |
AUC |
| –Main provider delivery nurse/midwife |
644 |
81.1 |
86.2 (82.9–89.0) |
73.0 (64.2–80.6) |
75.0 |
0.80 (0.76–0.83) |
0.93 |
Both |
| Main provider delivery student nurse |
644 |
4.8 |
16.1 (5.5–33.7) |
98.5 (97.2–99.3) |
2.2 |
0.57 (0.53–0.61) |
0.45 |
|
|
Second and third stage labor: |
||||||||
| Episiotomy performed |
545 |
18.2 |
82.8 (73.9–89.7) |
90.4 (87.2–92.9) |
22.9 |
0.87 (0.83–0.89) |
1.26 |
AUC |
| Uterotonic received following delivery of placenta |
552 |
2.4 |
53.9 (25.1–80.8) |
40.8 (36.6–45.1) |
59.1 |
0.47 (0.43–0.52) |
25.1 |
|
|
Immediate newborn postnatal care: | ||||||||
| Baby given to mother immediately after birth |
611 |
57.6 |
66.5 (61.3–71.4) |
49.0 (42.8–55.3) |
59.9 |
0.58 (0.54–0.62) |
1.04 |
IF |
| Baby placed immediately skin to skin on mother |
602 |
16.3 |
78.6 (69.1–86.2) |
21.0 (17.6–24.9) |
78.9 |
0.50 (0.46–0.54) |
4.85 |
|
| Baby placed immediately skin to skin on mother (2 item)† |
596 |
16.2 |
26.8 (18.3–36.8) |
70.3 (66.1–74.3) |
29.2 |
0.49 (0.44–0.53) |
1.80 |
|
| Breastfeeding within first hour of birth |
551 |
53.0 |
88.4 (84.1–91.8) |
37.1 (31.2–43.3) |
76.4 |
0.63 (0.59–0.67) |
1.44 |
|
| 3 elements of essential newborn care (immediately dried, on mother’s skin, breastfed within first hour) |
506 |
9.3 |
70.2 (55.1–82.7) |
28.3 (24.2–32.7) |
71.5 |
0.49 (0.45–0.54) |
7.70 |
|
| 3 elements of essential newborn care (immediately dried, 2 item on mother’s skin‡, breastfed within first hour) |
501 |
9.2 |
19.6 (9.4–33.9) |
74.3 (70.0–78.2) |
25.2 |
0.47 (0.42–0.51) |
2.7 |
|
| Low birthweight newborn (<2500g) |
579 |
7.8 |
71.1 (55.7–83.6) |
98.7 (97.3–99.5) |
6.7 |
0.85 (0.82–0.88) |
0.87 |
Both |
|
Immediate postnatal care for mother: | ||||||||
| Palpates uterus 15 min after delivery of placenta |
557 |
70.2 |
88.8 (85.2–91.7) |
12.7 (8.0–18.7) |
88.3 |
0.51 (0.46–0.55) |
1.26 |
|
| First post–delivery exam, provider ask/checks for bleeding |
627 |
90.6 |
59.9 (55.7–63.9) |
17.0 (8.4–29.0) |
62.0 |
0.38 (0.35–0.42) |
0.68 |
|
| First post–delivery exam, provider examines perineum |
554 |
87.4 |
57.9 (53.3–62.3) |
55.7 (43.3–67.6) |
56.1 |
0.57 (0.53–0.61) |
0.64 |
|
| First post–delivery exam, provider takes temperature |
638 |
40.3 |
88.1 (69.3–80.3) |
50.1 (45.0–55.3) |
60.0 |
0.63 (0.59–0.66) |
1.49 |
|
| First post–delivery exam, provider takes blood pressure |
642 |
48.3 |
88.1 (85.1–92.5) |
38.0 (32.3–43.5) |
74.6 |
0.63 (0.59–0.67) |
1.55 |
|
| First post–delivery exam, provider checks for involution |
615 |
78.2 |
64.0 (59.6–68.3) |
35.1 (27.0–43.8) |
64.2 |
0.50 (0.46–0.54) |
0.82 |
IF |
| Woman asked for pain relief medication during stay |
638 |
10.5 |
35.8 (24.5–48.5) |
68.3 (64.3–72.1) |
32.1 |
0.52 (0.48–0.56) |
3.06 |
|
| Woman received pain relief medication |
640 |
17.5 |
85.7 (77.8–91.6) |
46.2 (41.9–50.6) |
59.4 |
0.66 (0.62–0.70) |
3.39 |
|
|
Maternal outcomes: | ||||||||
| Cesarean section (C/S) performed |
651 |
1.4 |
93.1 (85.6–97.4) |
98.8 (97.5–99.5) |
13.5 |
0.96 (0.94–0.97) |
1.01 |
Both |
| Reason for C/S– prolonged/obstructed labor |
76 |
67.1 |
39.2 (25.8–53.9) |
80.0 (59.3–93.2) |
32.9 |
0.60 (0.47–0.70) |
0.49 |
|
| Complications (any): |
654 |
11.0 |
62.5 (50.3–73.6) |
57.4 (53.3–61.4) |
44.8 |
0.60 (0.56–0.64) |
4.07 |
|
| –Hemorrhage |
654 |
4.6 |
33.3 (17.3–52.8) |
89.9 (87.3–92.2) |
11.2 |
0.62 (0.58–0.65) |
2.43 |
|
| –Prolonged labor |
654 |
3.7 |
50.0 (29.1–70.9) |
77.3 (73.8–80.5) |
23.7 |
0.64 (0.60–0.67) |
6.46 |
|
| –None | 654 | 89.0 | 53.8 (49.6–57.9) | 66.7 (54.6–77.3) | 51.5 | 0.60 (0.56–0.64) | 0.58 | |
CI – confidence interval; IF – inflation factor; AUC – receiver operating curve
Recommended indicators met both AUC and IF validation criteria.
*Validation analysis based on matched data, excluding ‘Don’t Know’ responses. Sensitivity and specificity analysis was not performed for indicators that had fewer than 5 counts per cell.
†Skilled provider includes doctor (ob–gyn), medical resident or nurse/midwife.
‡Indicator constructed from two skin–to–skin items: (1) newborn placed against mother’s chest after delivery and (2) newborn was lying naked against the mother’s chest.