Monthly Service Delivery Report Form.

Private Clinic Name ____________________ Month___________

Year ____________

HMIS_code Activity Number

Reproductive, Maternal, Neonatal, Child, Adolescent and Youth Health-
RMNCH
Nutrition
RMH Reproductive & Maternal Health
MAT_CAR Contraceptive acceptance rate
MAT_CAR_Age Total new and repeat acceptors, disaggregated by age
MAT_CAR_Age.1 Contraceptive new acceptors by age
MAT_CAR_Age.1.1 10 - 14 years
MAT_CAR_Age.1.2 15 - 19 years
MAT_CAR_Age.1.3 20 - 24 years
MAT_CAR_Age.1.4 25 - 29 years
MAT_CAR_Age.1.5 30 - 49 years
MAT_CAR_Age.2 Repeat acceptors by age
MAT_CAR_Age.2.1 10 - 14 years
MAT_CAR_Age.2.2 15-19 years
MAT_CAR_Age.2.3 20 - 24 years
MAT_CAR_Age.2.4 25 -29 years
MAT_CAR_Age.2.5 30 - 49 years
MAT_CAR_Mtd Total new and repeat acceptors, disaggregated by method
MAT_CAR_Mtd.1 New acceptors, by method
MAT_CAR_Mtd.1.1 Oral contraceptives
MAT_CAR_Mtd.1.2 Injectables
MAT_CAR_Mtd.1.3 Implants
MAT_CAR_Mtd.1.4 IUCD
MAT_CAR_Mtd.1.5 Vasectomy
MAT_CAR_Mtd.1.6 Tubal ligation
MAT_CAR_Mtd.1.7 Others
MAT_CAR_Mtd.2 Repeat acceptors, by method
MAT_CAR_Mtd.2.1 Oral contraceptives
MAT_CAR_Mtd.2.2 Injectables
MAT_CAR_Mtd.2.3 Implants
MAT_CAR_Mtd.2.4 IUCD
MAT_CAR_Mtd.2.5 Vasectomy
MAT_CAR_Mtd.2.6 Tubal ligation
MAT_CAR_Mtd.2.7 Others
MAT_IPPCAR Immediate Postpartum Contraceptive Acceptance(IPPCAR)
MAT_IPPCAR_Age Total PPFP acceptors, disaggregated by age
MAT_IPPCAR_Age.1 10 - 14 years
MAT_IPPCAR_Age.2 15-19 years
MAT_IPPCAR_Age.3 20 - 24 years
MAT_IPPCAR_Age.4 25 -29 years
MAT_IPPCAR_Age.5 30 - 49 years
MAT_IPPCAR_Mtd Total PPFP acceptors, disaggregated by method
MAT_IPPCAR_Mtd.1 Pills(POP)
MAT_IPPCAR_Mtd.2 Implants
MAT_IPPCAR_Mtd.3 IUCD
MAT_IPPCAR_Mtd.4 Tubal Ligation
MAT_IPPCAR_Mtd.5 Others
MAT_LAFPPR Premature Removal of Long term family planning methods (PRLAFP)
MAT_LAFPPR.1 Total number of premature removal of LAFP within 6 month insertion
MAT_LAFPPR.1.1 Implants
MAT_LAFPPR.1.2 IUCD
MAT_LAFPPR.1.3 Others
MAT_TLAFPR Total LAFP removal in the reporting period
MAT_ANC1 Antenatal Care coverage -First visit

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 Total Number of pregnant women that received ANC First visit by
MAT_ANC1_GA.1
gestational Age
MAT_ANC1_GA.1.1 <= 12 weeks
MAT_ANC1_GA.1.2 > 12 and <=16 weeks
MAT_ANC1_GA.1.3 > 16 weeks
MAT_ANC1_MA.1 Number of pregnant women that received ANC first visit by maternal age
MAT_ANC1_MA.1.1 10-14 years
MAT_ANC1_MA.1.2 15-19 years
MAT_ANC1_MA.1.3 >= 20 years
MAT_ANC4+ Antenatal care coverage - four visits
Total number of pregnant women that received four antenatal care visits
MAT_ANC4+_GA.1
by gestational age
MAT_ANC4+_GA.1.1 < 30 weeks
MAT_ANC4+_GA.1.2 > = 30 weeks
MAT_ANC4+_MA.1 Total number of pregnant women that received four antenatal care visits
MAT_ANC4+_MA.1.1 10-14 years
MAT_ANC4+_MA.1.2 15-19 years
MAT_ANC4+_MA.1.3 >= 20 years
MAT_ANC8+ Antenatal care coverage - Eigth visits
Number of pregnant women that received antenatal care –8 Contacts
MAT_ANC8+
and more
MAT_SYPH Pregnant women attending antenatal care tested for syphilis
MAT_SYPH.1 Total Number of pregnant women tested for syphilis
MAT_SYPH_Rct.1 Test result-Reactive
MAT_SYPH_NRct.1 Test Result- Non-Reactive
MAT_SYPH.RX.1 Total Number of pregnant women treated for syphilis
Total Number of Pregnant women attending antenatal care tested for
MAT_Hepa
hepatitis (B&C)
MAT_Hepa_Rct.1 Test result :Reactive
MAT_Hepa_NRct.1 Test result :Non-Reactive
MAT_Prp Proportion of pregnant women who were received prophylaxis for HBV
Total Number of pregnant women who were received prophylaxis for
MAT_Prp.1
HBV
MAT_SBA Births attended by skilled health personnel coverage
MAT_SBA.1 Total Number of births attended by skilled health personnel
MAT_PPH Percentage of women who developed Postpartum hemorrhage (PPH)
MAT_PPH.1 Total number of women who developed postpartum hemorrhage (PPH)
MAT_PPH.Hom.1 Home delivery
MAT_PPH.facil.1 Facility delivery
Percentage women who received uterotonics in the first one minute after
MAT_UTER
delivery
Total number of women who received uterotonics in the first one minute
MAT_UTER.1
after delivery
MAT_UTR.type.1.1 Oxytocin
MAT_UTR.type.1.2 Mesoprostol
MAT_UTR.type.1.3 Ergometrin
MAT_UTR.type.1.4 Other
MAT_SBR Still birth rate
MAT_SBR.SB Number of still births
MAT_SBR.LB Number of Live births
MAT_B&D Birth and Death Notifications
MAT_B&D_IBN.1 Number of Institutional Births notified
MAT_B&D_IDN.2 Number of Institutional death notified
MAT_EPNC Early Postnatal Care Coverage
MAT_EPNC.1 Number of postnatal visits within 7 days of delivery
MAT_EPNC.1.0 Early first postnatal care attendances 0-24 hrs
MAT_EPNC.1.1 Early first postnatal care attendances 24 hrs (1 days)
MAT_EPNC.1.2 Early first postnatal care attendances 25-48 hrs
MAT_EPNC.1.3 Early first postnatal care attendances 49-72 hrs

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MAT_EPNC.1.4 Early first postnatal care attendances 73hrs-7 days
MAT_CS Caesarean section rate
MAT_CS.1 Number of women having given birth by caesarean section
MAT_CAC Number of women receiving comprehensive abortion care services
MAT_CAC_SAC Number of safe abortions performed
MAT_CAC_SA.1 10-14 yr
MAT_CAC_SA.2 15-19 yr
MAT_CAC_SA.3 20-24 yr
MAT_CAC_SA.4 25-29 yr
MAT_CAC_SA.5 30+ yr
MAT_CAC_PAC Number of post abortion/emergency care
MAT_CAC_PAC.1 10-14 yr
MAT_CAC_PAC.2 15-19 yr
MAT_CAC_PAC.3 20-24 yr
MAT_CAC_PAC.4 25-29 yr
MAT_CAC_PAC.5 30+ yr
Number of women receiving comprehensive abortion care disaggregated
MAT_CAC.Tr.1
by trimester
MAT_CAC.Tr.1.1 First Trimester (<12 weeks)
MAT_CAC.Tr.1.2 Second Trimester (≥12 - 28 weeks)
Number of women receiving comprehensive abortion care disaggregated
MAT_CAC.MA.1
by Methods
MAT_CAC.MA.1.1 POP
MAT_CAC.MA.1.2 Implants
MAT_CAC.MA.1.3 IUCD
MAT_CAC.MA.1.4 Tuba Ligation
MAT_CAC.MA.1.5 Others
MAT_OFC.Ide Number of confirmed obstetric fistula cases identified
MAT_OFC_Ide__Age Number of confirmed fistula cases identified by Age
MAT_Ide_Age.1.1 10-14 yr
MAT_Ide_Age.1.2 15-19 yr
MAT_Ide_Age.1.3 20-24 yr
MAT_Ide_Age.1.4 25-29 yr
MAT_Ide_Age.1.5 30+ yr
MAT_OFC.Treat Proportion of obstetric fistula cases treated
MAT_OFC_Treat__Age Number of obstetric fistula cases treated by Age
MAT_Treat_Age.1.1 10-14 yr
MAT_Treat_Age.1.2 15-19 yr
MAT_Treat_Age.1.3 20-24 yr
MAT_Treat_Age.1.4 25-29 yr
MAT_Treat_Age.1.5 30+ yr
MAT_IMD Institutional maternal deaths
MAT_IMD.1 Number of maternal deaths in health facility
MAT_TngP_TPR Total number of teenage girls tested positive for pregnancy
MAT_TngP_TPR.1 10-14 years
MAT_TngP_TPR.2 15-19 years
MAT_Tngtst Total number of women tested for pregnancy
MTCT PMTCT
Pregnant and lactating women who were tested for HIV and know their
MTCT_TST
results
Number of pregnant women tested and know their result during
MTCT_TST.1
pregnancy
Number of pregnant women tested and know their result during
MTCT_TST.2
labour & delivery
Number of women tested and know their result during the
MTCT_TST.3
postpartum period
Number of women with known HIV positive status attending ANC,
MTCT_Test.4
delivery and postpartum for new pregnancy linked from Pre and ART
MTCT_NWpos Number of new Postive womens during ANC,L&D and Postpartum
MTCT_ART Percentage of HIV-positive pregnant women who received ART to reduce

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 the risk of mother-to child-transmission (MTCT) during pregnancy, L&D and
PNC
Number of HIV positive Pregnant women who received ART to reduce
MTCT_ART.1
the risk of mother to child transmission during ANC for the first time
Number of HIV positive Pregnant women who received ART to reduce
MTCT_ART.2
the risk of mother to child transmission during L&D for the first time
Number of HIV positive lactating women who received ART to reduce
MTCT_ART.3
the risk of mother to child transmission during PNC for the first time
Number of HIV-positive women who get pregnant while on ART and
MTCT_ART.4
linked to ANC
MTCT_HEI_EID.1 Total Number of infants within 12 month received virological test result
Number of HIV exposed infants who received an HIV test 0- 2 months of
MTCT_HEI_EID.1.1
birth:
MTCT_HEI_EID.1.1.1 :Positive
MTCT_HEI_EID.1.1.2 :Negative
Number of HIV exposed infants who received an HIV test 2-12 months of
MTCT_HEI_EID.1.2
birth
MTCT_HEI_EID.1.2.1 :Positive
MTCT_HEI_EID.1.2.2 :Negative
Percentage of exposed Infants born to HIV positive women who were
MTCT_HEI_COTR
started on co-trimoxazole prophylaxis within two months of birth
Number of infants born to HIV positive women started on co-
MTCT_HEI_COTR.1
trimoxazole prophylaxis within two months of birth
Percentage of exposed Infants born to HIV positive women receiving
MTCT_HEI_ARV antiretroviral (ARV) prophylaxis for prevention of Women-to-child
transmission (PMTCT)
Number of HIV exposed infants who received ARV prophylaxis For
MTCT_HEI_ARV.1
12 weeks
MTCT_HEI_ARV.2 Number of HIV positive women who gave birth at health institution
Percentage of partners of pregnant, laboring and lactating women tested
MTCT_PMTCT_PRN_TST
for HIV in the reporting month/period
Total Number of partners of pregnant ,laboring and lactating women
MTCT_PRN_TST.1
tested and know their results
Number of partners of pregnant, laboring and lactating women whose
MTCT_PRN_TST.2
test result is HIV positive
Percentage of HIV exposed infants receiving HIV confirmatory (antibody
MTCT_HEI_ABTST
test) test by 18 months
Number of HIV exposed infants receiving HIV confirmatory (antibody
MTCT_HEI_ABTST.1
test) by 18 months
MTCT_HEI_ABTST_Pos.
HIV positive
1
MTCT_HEI_ABTST_Neg
HIV negative
.1

Reported by __________________________

Report sent date _____________

Signature ______________________

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