Indicator 16: Neonatal inpatient mortality rate

Some deaths among small and sick newborns can be averted with high quality inpatient care in specialized units (i.e., SNCUs or NICUs). The neonatal inpatient mortality rate provides planners and implementers an overall picture of the outcome of inpatient care provided to small and sick newborns, and is therefore central to understanding the impact of EmONC service delivery.

Some of the neonatal deaths captured by this indicator are also included in the calculation for Indicator 15: Intrapartum stillbirth and very early neonatal death rate. The distinctions between these two indicators are explained in Differences between Indicators 15 and 16.

The numerator is the number of newborns admitted to the inpatient newborn care unit who die before discharge. The denominator is the number of newborns admitted to the inpatient newborn care unit who were not referred out. Since this indicator represents a subset of the neonatal mortality rate, it should only be measured among infants aged 0-27 days.¹ The numerator and denominator should be calculated for the same time period, and only from facilities that are expected to have inpatient newborn care units (in some countries called special newborn care units or “SNCUs” or neonatal intensive care units or “NICUs”). If it is not known which facilities those are, one can instead look at facilities that have been designated to be Comprehensive or Intensive EmONC facilities (regardless of whether they are performing at that level or not). If EmONC designation status is unknown, this indicator can be calculated among all hospitals instead.

Data for this indicator are likely to be available in the HMIS. The data originate in patient records, pediatric registers, special newborn care unit registers, neonatal intensive care unit registers, and morgue records. Quality and completeness of data in registers varies but generally need improvement. Initiatives such as Maternal and Perinatal Death Surveillance and Response (MPDSR) and tools such as the EN-MINI² are designed to help countries strengthen and improve HMIS data.

This indicator is expressed as a percentage.

The stability of any rate depends on a large enough number in the numerator and accurate denominators. WHO cautions the use of case fatality rates when the numerator is small; this will affect the frequency of calculation. Even if data for this indicator are collected routinely in the HMIS, the neonatal inpatient mortality rate is most usefully calculated and analyzed on an annual basis.

There is no benchmark for this indicator; governments should set their own targets. The aggregated statistic at a national level does not identify which facilities are contributing most to the neonatal inpatient mortality rate. Therefore, disaggregation by sub-national area, level of facility, managing authority of facility and EmONC classification can be used to understand patterns and to determine where to focus attention. The neonatal inpatient mortality rate for a given time and area of interest can be compared to national targets or between different time periods to look at change over time. When the rate is higher, it suggests that the inpatient care for small and sick newborns may require improvement.

This indicator can be further disaggregated by birthweight to better understand case mix, as facilities with high numbers of very small babies will have higher mortality rates. By analyzing this indicator with other EmONC indicators, including health workforce, infrastructure, and equipment, drugs and supplies, other factors may be revealed.

Unlike some of the other indicators, this indicator can also be used for individual facility level monitoring to help identify hotspots for prioritization and specific newborn related interventions.

Calculating adherence to selected standards of care indicators

When facilities have higher neonatal inpatient mortality rates, it is important to identify why and then implement and monitor solutions. One effective way to improve outcomes is to assess whether the provision of EmONC has been performed according to WHO standards of care. A set of indicators for this purpose, along with instructions for their use, can be found in Adherence to selected standards of care indicators.

The neonatal inpatient mortality rate for small and sick newborns referred in from other facilities

The neonatal inpatient mortality rate for small and sick newborns who were referred in from other facilities can be compared with the neonatal inpatient mortality rate for inborn small and sick newborns. If neonatal inpatient mortality rates are much higher for newborns being referred in, it may be indicative of referral problems as opposed to the quality of care at receiving facilities.