Maternal and Child Health

MODEL INDICATORS

EXECUTIVE SUMMARY

Division of Science, Education and Analysis Maternal and Child Health Bureau

Maternal and Child Health Information Resource Center         Maternal and Child Health Model Indicators Executive Summary

            Prepared by: MCH Model Indicators Working Group Charlyn Cassady, Johns Hopkins University Anita Farel, University of North Carolina Priscilla Guild, University of North Carolina Joan Kennelly, University of Illinois at Chicago Mary Peoples-Sheps (Chair), University of North Carolina Patricia Potrzebowski, Pennsylvania Dept. of Health Cheryl Waller, University of North Carolina       December 1997       Contract No. 240-94-0047       Prepared for: Division of Science, Education, and Analysis Maternal and Child Health Bureau, HRSA, PHS, DHHS Parklawn Building 5600 Fishers Lane Rockville, Maryland 20857

A set of Maternal and Child Health (MCH) Model Indicators (MI), to be used as a barometer of the health of mothers and children in the United States and as a guide to the content of MCH data sources in the future, is presented in this report. The MCH MI were developed under the leadership of the Maternal and Child Health Bureau (MCHB), USDHHS, through a contract with the Public Health Foundation’s Maternal and Child Health Information Resource Center (MCHIRC) and subcontracts with selected universities and organizations represented by the MCH MI Working Group.

The MCH Model Indicators have a broad mission: to provide a panoramic view of the health of mothers and children, within a framework that encourages problem-solving. They include indicators capable of serving such diverse functions as needs assessment, policy and program development, evaluation, resource allocation, program and policy monitoring, quality assurance, and accountability. These indicators are not intended to be promulgated as requirements for any reporting or funding mechanism, although some of them are identical to required items in the Omnibus Budget Reconciliation Act of 1989 and to the new MCHB Title V Performance and Outcome Measures.

The health concerns of mothers and children are extensive. To establish boundaries for the project and to promote consistency in the selection of indicators, the following principles were developed and applied:

1. The MCH Model Indicators are a collection of measures that, taken together, give an indication of the health of mothers and children and corresponding needs for specific actions.
1. The indicators should build on existing work (e.g., regional projects of MCHB, Healthy People 2000), and be consistent with reporting requirements (e.g. OBRA ’89, MCHB Performance Measures).
2. The indicators as a group should reflect the health of the full population of women of reproductive age and children of all ages.
3. Women’s health indicators should be limited to reproductive conditions or conditions of women that are likely to have a major impact on the family (e.g., mental illness).
4. The indicators should fit into a framework that encourages useful analysis and interpretation.
5. To be immediately applicable, most of the indicators should be amenable to construction from existing data sources.
6. To encourage development of new data sources and refinement of existing ones so that they meet current needs for data in MCH more effectively, a small number of critical indicators should be recommended regardless of data availability.
7. To provide guidance for users who cannot produce all of the indicators, they should be categorized according to level of importance for routine surveillance.
8. The indicators are for the use of MCH practitioners in carrying out their assessment, policy development, and assurance roles. While the indicators may also be applied to research purposes, they were not developed for research.
9. Decisions about indicator content and measurement should begin with state-of-the- art research findings, modified to reflect the realities of MCH practice and data availability.
10. Participation of a broad array of MCH and related professionals is essential to satisfy many of these principles and to encourage use of the indicators in the future.

The conceptual model used to guide development of the MCH MI has five domains: health status, risk/protective status, health and related services, health systems capacity and adequacy, and contextual characteristics. Within each domain, categories of indicators were identified. Thus, the model served as a framework for selection of indicators within specified categories in each domain. It also provides a blueprint for analysis of the indicators and identification of needed interventions. The MCH Model Indicators are stored in a Filemaker Pro database. Filemaker Pro is a versatile program that is available for both IBM-type and Apple Macintosh computers. It has the capability to prepare self-contained databases that can be opened by a user who does not own the program. The database presently provides several views of the data, sorted by the specific characteristics and response options described in Table 1. The database is flexible, future-oriented, and designed to communicate its potential to users. Additional information is easily added; additional indicators can be appended; and the information is easily retrieved, sorted, and formatted for a variety of printed reports. In the database, health status indicators have the most complete descriptions, followed by contextual and health systems indicators. These indicators have importance codes of core (N=20) or recommended (N=55 health status, 9 contextual, 16 health systems) for routine surveillance. Indicators of risk/protective status and health and related services include relatively less information. They are presented as optional for routine surveillance or investigation of health status indicators that reach levels of concern (N=49 risk/protective, 68 health and related services). The MCH Model Indicators are listed by level of importance, domain, category, and population group in Table 2. To use the MCH MI, three technical issues should be considered:

1. Availability of data: Most of the health status, contextual, and health systems indicators can be calculated from existing data sources, identified in the database and described in Appendix B of the report. Many of the risk/protective and health service indicators, however, depend on local data sources which vary across indicators, populations, and geographic areas.
1. Rare events: Rare events present unique problems when used in rates or proportions, especially for sparsely populated geographic areas and in age, gender or race-specific population groups. Indicators based on rare events should be treated with care, perhaps combining cases across years and/or population groups to increase frequencies.
2. Model-based (synthetic) estimation: National or state level surveys are the only known sources of data for some of the indicators. To use these data to calculate rates in smaller geographic areas, model-based (synthetic) estimation techniques must be applied. Synthetic estimation involves applying the rate of a condition derived from a survey to population data in the geographic area of interest, thus producing an estimate of the number of cases of the condition in the local population.

Each of these technical issues is complex. Guidance on how to manage them in order to produce useful indicators is included in this report. The MCH Model Indicators were developed within the framework of a conceptual model that also serves as a guide to interpretation. By showing primary relationships among the domains, the model suggests how surveillance of the indicators might be conducted. Figure 1 is an example. Here, the neural tube defects (NTDs) prevalence rate is a core Model Indicator that should be monitored on a regular basis. An unacceptably high rate of NTDs would trigger assessment of indicators of risk/protection for NTDs (e.g., knowledge about folate therapy on the part of women of childbearing ages and providers of primary care) and use of appropriate interventions or services (e.g., periconceptional folate therapy, preconceptional risk assessment). Results of this assessment may lead to questions about the health system in which services are offered (e.g., use of MCH/CSHCN standards of care, mortality reviews, provider availability) and the larger context in which the problem exists (e.g., levels of poverty and educational achievement). With this understanding of several dimensions of the problem of NTDs, decisions can be made about what to investigate further (e.g., why women are not aware of the importance of periconceptional folate therapy) and which interventions are needed to address the NTD problem. Relationships among health status, risk/protective, and health service indicators are coded in the MCH MI database to facilitate analyses like the one described above. In the report, additional examples of how indicators might be combined to better understand health problems and identify solutions are presented. The MCH Model Indicators should be disseminated widely for implementation by health and related units with interests in Maternal and Child Health. At the same time, however, the next steps in development of the MCH MI should be undertaken so that while the field gains experience with a model set of indicators, the set itself is being perfected. Also, regular revisions are essential if the MCH Model Indicators are to continue to be responsive to needs for MCH information. The MCH MI represent a large step forward in a process that started in the early 1980s to develop measures of MCH with standard definitions that would support comparisons across jurisdictional and organizational boundaries. Developed with input from numerous people involved in Maternal and Child Health, including local, state and federal program personnel, advocates for MCH population groups, professional organization staff members, academicians, and researchers, this set of Model Indicators is offered to the MCH community by the MCH community as the next step in this ongoing process.

Table 1 MCH Model Indicators Characteristics in the Database

and Response Options.

  Indicator ID: Alphanumeric code assigned to each indicator Indicator name: Descriptive name Formula: Numerator, denominator and multiplier. Formulas are presented as rates, proportions, or frequency counts. Indicators of extremely rare events are presented as rates or proportions if one of these is the conventional manner of reporting. Otherwise they are presented as frequency counts. Domain: One of the following:

	Health status
	Risk/protective status
	Health and related services
	Contextual characteristics
	Health system capacity and adequacy

Category: Category within the selected domain, as listed in Table 1 Subcategory: Subcategory within selected category, as listed in Table 1 Population groups: Standard age groups for children are <1, 1-4, 5-9, 10-14, 15-19, and 0-19. Standard groups for women are 15-17, 18-19, 20-34, and 35-44. Non-standard age groups and gender strata (for infants, children and adolescents) are recommended when research findings and/or data availability suggest that they should be. The phrase in specific population is used in many formulas and refers to the age/gender categories specified for the indicator.^* Recent values: The most recent values for each health status indicator stratified by the recommended age/gender groupings are presented whenever available. In many cases, the data available in published sources do not correspond exactly with recommended strata. For a few indicators, values could not be located in published materials, even when a data source was identified (e.g., sickle cell hospitalization rates). Reference for recent values: Reference for the recent value. Existing data source, numerator: One or more data sources required to calculate the numerator of the indicator. When more than one source is given, all of them are required. However, an understanding of the information that precedes this entry is important to accurate interpretation. In some cases, data from more than one source should be combined to produce the indicator. In other cases, different data sources are required to calculate the indicator for different population groups. Existing data source, denominator: One or more data sources required to calculate the denominator of the indicator. When more than one source is given, all of them are required. However, an understanding of the information that precedes this entry is important for accurate interpretation. In some cases, data from more than one source should be combined to produce the denominator. In other cases, different data sources are required to calculate the denominator for different population groups. If the indicator is based on survey data, both numerator and denominator are from the same data source. To use the values derived from national or state-level surveys in smaller areas, model-based (synthetic) estimation must be used. Availability of data sources required to produce the indicator:

	Routinely available at the local level (e.g., vital records)
	Sometimes available at the local level (e.g., birth defects registries)
	Sometimes available at the local level and collected through periodic national surveys (e.g., hospital discharge data)
	Routinely available at the state level, but not at the local level (e.g., Behavioral Risk Factor Surveillance System)
	Sometimes available at the state level, but not at the local level (e.g., PRAMS, YRBS)
	Only available from periodic national surveys (e.g., NHANES)
	Not routinely or periodically available at any level, requires a special survey

Importance:

	Core: Key health status Indicators that can be generated from existing data sources, and are representative of the major categories of health status (listed in Table 1), the range of age/gender population groups, and the levels of data source availability (e.g., all but the last category above). Core indicators should definitely be monitored on a routine basis in order to provide an ongoing picture of key aspects of the health of mothers and children.
	Recommended: Indicators of health status, contextual characteristics and health systems capacity and adequacy that provide a more detailed view of the health of mothers and children and should be monitored on a routine basis, if possible.
	Optional: Indicators that should be examined when related indicators in the other domains reach unacceptable levels.

Consistency with HP 2000 or OBRA ‘89:

	Same formula
	Same concept but uses a slightly different formula or population group
	Same concept but very different formula or population group
	Not in standards (either HP 2000 or OBRA ‘89)

Rationale for including in the MCH MI: Reason for inclusion. Other references: References for general reading about the importance of the condition represented by the indicator and relevant measurement issues. Comments: Statements about noteworthy aspects of the indicators, including substantive definitions of conditions, discussions of measurement issues, and observations about any of the characteristics listed above. Relationships: Associations among indicators. Relationships are noted for health status, risk/protective and health service indicators. In most cases, these relationships constitute a rationale for including the risk/protective and health service indicators in the MI. Other relationships that may be documented in the literature are not noted here because a systematic search for all other relationships was not conducted. The contextual and health systems indicators are extensively interconnected with the others. These relationships are not listed because the lists would be lengthy and repetitious and the relationships are fairly well-known.