Community medicine chapters
Health, demographic, fertility and MCH indicators
How the main mortality, fertility, demographic and mother-and-child health indicators are defined and calculated, with worked examples and the latest Pakistani figures and where to check them.
- Rates use a defined population at risk: crude birth and death rates per 1,000 mid-year population; infant (IMR) and neonatal (NMR) mortality per 1,000 live births; maternal mortality ratio (MMR) per 100,000 live births.
- IMR is the best single indicator of a community's health and living standards; perinatal mortality includes stillbirths and early neonatal deaths.
- Pakistan (latest national surveys): NMR 42, IMR 62, under-5 mortality 74 per 1,000 live births (PDHS 2017-18); MMR 186 per 100,000 (2019); TFR 3.6; population about 241.5 million (Census 2023).
On this page
Overview
Health indicators are measures that show the health of a population, allow comparison between places and over time, and guide planning.
Most are rates: the number of events divided by the population at risk in a given time, multiplied by a constant (1,000 or 100,000).
Characteristics of a good indicator
Valid (measures what it should), reliable (gives the same result on repetition), sensitive to change, specific, feasible to collect, and relevant to planning.
Mortality indicators
| Indicator | Formula |
|---|---|
| Crude death rate (CDR) | Deaths in the year ÷ mid-year population × 1,000 |
| Infant mortality rate (IMR) | Deaths under 1 year ÷ live births in the year × 1,000 |
| Neonatal mortality rate (NMR) | Deaths in the first 28 days ÷ live births × 1,000 |
| Early neonatal mortality | Deaths in the first 7 days ÷ live births × 1,000 |
| Post-neonatal mortality | Deaths from 28 days to under 1 year ÷ live births × 1,000 |
| Perinatal mortality rate (PMR) | (Stillbirths of 28 weeks or more + deaths in the first 7 days) ÷ (live births + stillbirths) × 1,000 |
| Under-5 mortality rate | Deaths under 5 years ÷ live births × 1,000 |
| Maternal mortality ratio (MMR) | Maternal deaths ÷ live births × 100,000 |
A maternal death is the death of a woman while pregnant or within 42 days of the end of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but not from accidental causes.
The IMR is the most sensitive single indicator of a community's health status and living standards.
The denominator of the perinatal mortality rate is total births (live births + stillbirths), because stillbirths are in the numerator. The IMR and NMR use live births only.
The maternal mortality ratio uses live births as the denominator, not the number of women at risk, so strictly it is a ratio, not a rate.
A district in one year: mid-year population 400,000; live births 5,000; stillbirths 100
Infant deaths 310, of which 210 in the first 28 days and 150 in the first 7 days
Maternal deaths 9
IMR = 310 ÷ 5,000 × 1,000 = 62 per 1,000 live births
NMR = 210 ÷ 5,000 × 1,000 = 42 per 1,000 live births
PMR = (100 + 150) ÷ (5,000 + 100) × 1,000 = 250 ÷ 5,100 × 1,000 = 49 per 1,000 total births
MMR = 9 ÷ 5,000 × 100,000 = 180 per 100,000 live births
Fertility indicators
| Indicator | Formula or meaning |
|---|---|
| Crude birth rate (CBR) | Live births in the year ÷ mid-year population × 1,000 |
| General fertility rate (GFR) | Live births ÷ women aged 15–49 × 1,000 |
| Age-specific fertility rate | Live births to women of an age group ÷ women in that group × 1,000 |
| Total fertility rate (TFR) | The average number of children a woman would have over her reproductive life at current age-specific rates (sum of age-specific rates × 5 ÷ 1,000 for 5-year groups) |
| Gross reproduction rate | Like TFR but counting daughters only |
| Net reproduction rate | Daughters who survive to reproductive age; NRR = 1 means the population will exactly replace itself |
Replacement-level fertility is a TFR of about 2.1.
Mid-year population 400,000; live births 12,000; deaths 2,800 in the year
CBR = 12,000 ÷ 400,000 × 1,000 = 30 per 1,000
CDR = 2,800 ÷ 400,000 × 1,000 = 7 per 1,000
Natural growth rate = CBR − CDR = 30 − 7 = 23 per 1,000 = 2.3% per year
Demographic indicators
- Growth rate: (births − deaths ± migration) per year as a percentage. The natural growth rate is CBR − CDR.
- Dependency ratio: (children 0–14 + adults 65 and over) ÷ people aged 15–64 × 100. A high ratio means many dependants for each working-age adult.
- Sex ratio: in Pakistan usually expressed as males per 100 females.
- Life expectancy at birth: the average years a newborn can expect to live at current death rates.
- Population pyramid: Pakistan has a broad-based (expanding) pyramid, typical of high fertility and a young population.
Population: 36% aged 0–14, 60% aged 15–64, 4% aged 65+
Dependency ratio = (36 + 4) ÷ 60 × 100 = 40 ÷ 60 × 100 = 66.7 dependants per 100 working-age adults
Other indicators
- Morbidity: incidence and prevalence (see incidence, prevalence and risk), notification rates, hospital admissions.
- Disability: DALYs (disability-adjusted life years: years lost to early death plus years lived with disability) and QALYs.
- Nutritional status: low birth weight, stunting, wasting and underweight in children.
- Health care delivery: doctor-population ratio, bed-population ratio, coverage of immunisation and antenatal care, skilled birth attendance.
Pakistan: latest national figures
| Indicator | Value | Source |
|---|---|---|
| Neonatal mortality | 42 per 1,000 live births | Pakistan Demographic and Health Survey 2017-18 |
| Infant mortality | 62 per 1,000 live births | PDHS 2017-18 |
| Under-5 mortality | 74 per 1,000 live births | PDHS 2017-18 |
| Total fertility rate | 3.6 children per woman | PDHS 2017-18 |
| Maternal mortality ratio | 186 per 100,000 live births | Pakistan Maternal Mortality Survey 2019 |
| Population | About 241.5 million; growth about 2.55% a year | Pakistan Bureau of Statistics, Census 2023 |
These figures change with each new survey and estimates differ between sources (for example UN agencies model their own values). Check the latest from the Pakistan Bureau of Statistics, the National Institute of Population Studies (PDHS) and WHO/UNICEF before quoting them in practice. In MCQs, the answer key usually follows the textbook or survey current when the paper was set.
Most infant deaths in Pakistan are neonatal, so improving care at and just after birth has the biggest effect on infant mortality.
Expect: the numerator and denominator of each indicator (especially perinatal mortality and MMR), the constant used (1,000 vs 100,000), the definition of a maternal death (42 days), TFR and replacement level, dependency ratio, simple calculations, and IMR as the best single indicator.
Quick revision
- CBR, CDR: per 1,000 mid-year population.
- IMR, NMR, under-5: per 1,000 live births.
- PMR: (stillbirths + first-week deaths) ÷ total births × 1,000.
- MMR: maternal deaths per 100,000 live births; maternal death up to 42 days after pregnancy.
- TFR: children per woman; replacement about 2.1.
- Dependency ratio: (0–14 + 65+) ÷ 15–64 × 100.
- Pakistan: NMR 42, IMR 62, U5MR 74, TFR 3.6 (PDHS 2017-18); MMR 186 (2019).
Written by The House Job from Excel Community Medicine and Park's Textbook of Preventive and Social Medicine (named in the UHS PGET syllabus), with Pakistani figures from the Pakistan Demographic and Health Survey 2017-18, the Pakistan Maternal Mortality Survey 2019 and the 2023 Census.
FAQ
What is the denominator for the infant mortality rate?
The number of live births in the same year.
How is the perinatal mortality rate calculated?
Stillbirths plus deaths in the first week of life, divided by total births (live births plus stillbirths), multiplied by 1,000.
What is the maternal mortality ratio in Pakistan?
186 per 100,000 live births according to the Pakistan Maternal Mortality Survey 2019; check newer sources, as figures are updated.
What is the total fertility rate?
The average number of children a woman would have over her reproductive life if current age-specific fertility rates continued.