National policy,legislation in relation to maternal health and welfare


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National policy,legislation in relation to maternal health and welfare

  2. 2. MATERNAL HEALTH INMEDEVIAL PERIOD Dates back to Vedic period between3000BC – 1400BC Indus valley civilization showed relies ofplanned cities and healthful living. Ayurveda and other system of medicinepractices by sages suggestscomprehensive concept of
  3. 3.  272 BC-236 BC King Ashoka a covert ofBuddhism built a number of hospitals.Midwives were given a lot of preferenceduring his time. They were consideredto be skillful and trustworthy. 200-300AD Sushruta also defines
  4. 4.  500-600 AD Vagbhata wrote AshtangaHridaya (8 limbs and heart). Potencyand procreative ability was one of thebranch of the 8 limbs. This book is the most concise expositionof
  5. 5.  1300-1600 AD Bhavaprakasha arenowned Indian treatise contains anexhaustive list of disease and theirsymptom and a complete list of drugs. It includes etiology and treatment ofsyphilis a disease brought to India byPortuguese
  6. 6. Maternal health in Pre-Independence period 1873-Birth and death registration Act waspassed. 1880-Vaccination Act was passed. 1931-Maternity and child welfare Bureauwas established under the Indian RedCross. 1946-Bhore Committee report
  7. 7.  Republic of India is a federal Republic (unionof states) Indian Central Government has focussed onimproving health of people sinceindependence. Life expectancy was 60 years then comparedto 69 years at present. Infant mortality rate was 150 compared to 32at
  8. 8.  A wide variety of programs were intendedfor vaious parts of the country to improvewelfare of women and
  9. 9. Terms Policies: course of actions, programmeof actions adopted by a person, groupor government. Policy Environment: the arena theprocess takes placein, government, media, public Policy
  10. 10. Policy making in healthadministration Gives a concrete shape to political and socialobjectives which government lays down inthe form of laws, rules and regulations. It defines the objectives and determines thechoice of actions. While formulation of any policy governmentappoints an expert committee for
  11. 11.  Eminent persons from differentspecializations may be appointed toconstitute a committee. Views of the committee have aninfluence on policy
  12. 12. Stategies for health planning Constitution of India National development Council Planning Commission Advisory Bodies Ministry of health and family
  13. 13.  Health care measures formulated andimplemented in the successive 5 yearplans were based on approachesrecommended by health Committeesconstituted by Government of
  14. 14. Committees and comissions NPC committee on National Health (ColSantok Singh Sokhey) Health Survey and developmentcommittee (Sir Joseph Bhore) Nursing Committee to review conditionson nursing (Shri Shetty 1954) Special Committee on NMEP (Dr. MSChadda)
  15. 15.  Committee to review strategy of familyplanning (Shri Mukherjee) Committee on integration of health services(Dr Jungulwala) Committee for reviewing staffing pattern andfinancial provisions for FFP (Shri Mukherjee) Committee on Multipurpose workersunder H and FW (Kartar Singh)
  16. 16.  Group on medical education and Support Manpower(Dr.JB Shrivastava) National health Policy(1983) Medical education review Committee (Shri Mehta) Working group on Medical education and trainingManpower (Planning Comission) Committee on Health Manpower planning (Dr.Bajaj) High Power Commission on nursing and NursingProfession (Sarojini Varadappan)
  17. 17. Development of legislation inmidwifery education William Rathbone formed VisitingNurse‟s Association at England. It is influenced in India, because ofterrible condition, under which childrenwere born recognised as cause for highmortality rate. Because untrained „Dais‟are attending women at the time ofchild
  18. 18.  Dais were unwilling to trained andpatients will to accept the oldcustomary methods. In 1926 –Midwives Registration Act formed forthe purpose of better training
  19. 19. ESTABLISHMENT OF INDIANNURSING COUNCIL The INC was constituted to establish auniform standard of education fornurses, midwives, health visitors andauxiliary nurse midwives. The INC actwas passed following an ordinance onDecember 31st 1947 . The council wasconstituted in
  20. 20. MAIN PURPOSES OF THECOUNCIL1. To set standards and to regulate thenursing education of all types in the country.2. To prescribe and specify minimumrequirement for qualifying for a particularcourse in nursing.3. Advisory role in the state nursing council4. To collaborate with state nursing councils,schools and colleges of nursing andexamination
  21. 21. STATE REGISTRATIONCOUNCIL. 1. Inspect and accredit schools ofnursing in their state .2. Conduct the examinations3. Prescribe rules of conduct.4. Maintain registers ofnurses, midwives, ANM and healthvisitors in the
  22. 22. RECOMMENDATIONS OF VARIOUSCOMMITTEES PERTAINING TO NURSINGEDUCATION.1. Health survey and developmentcommittee ( Bhore committee 1946)a. Establishment of nursing college.b. Creation of an all India
  23. 23.  2. Shetty committee 1954a. Improvement in conditions oftraining of nurses.b. Minimum requirement for admissionto be in accordance with regulation ofthe
  24. 24. Health Survey and planningcommittee(Mudhaliar Committee 1959-61)1.Three grades of nurses viz. the basic nurses(4yrs), auxiliary nurse midwife (2yrs) andnurses with a degree qualification.2.For GNM minimum entrance qualificationmatriculation .3.For degree course passed highersecondary or pre university.4.Medium of instruction preferably English inGeneral nursing.5.Degree course should be taught only
  25. 25. 4. Mukherjeecommittee, 1966. a. Training of nurses and ANM‟Srequired for family planning.5. Kartar singh committee,1972-73a. Multipurpose health worker schemeb . Change in designation of ANM‟s andLHVc. Setting up of training division at theministry of health and family
  26. 26. 7. Sarojini varadappan committee, 1990(A high power committee on nursing andnursing profession.) a. Two levels of nursing personnelb. Post basic BSc nursing degree tocontinuec. Masters in nursing programme to beincreased and strengthened.d. Doctorate in nursing programme tobe started in selected university.e. Continuing education and staffdevelopment for
  27. 27. 8. Working group on nursingeducation and manpower,1991. a. By 2020 the GNM programme to be phasedoutb. Curriculum of BSc nursing to be modifiedc. Staffing norm should be as per INCd. There should be deliberate plan forpreparation of teachers MSc/Mphil and PhDdegrees.e. Improvement in functioning of INCf. Importance of continuing education
  28. 28. DEVELOPMENT OF NURSINGEDUCATIION. Training of diasThe Dai training continued pastindependence. The goal was to train one Daiin each village and ultimate goal was to trainall the practicing Dais in countryDuration of training was 30 days. No age limitwas prescribed, training include theory andpractice, more emphasis on field practice.This training was done at sub centre andequipments provided by
  29. 29. Auxillary Nurse Midwife In 1950 Indian Nursing Council came out with an important decisionthat there should be only two standard of training nursing andmidwifery, subsequently the curriculum for these courses wereprescribed.The first course was started at St. Marys Hospital Punjab,1951.Theentrance qualification was up to 7/8 years of schooling. The period oftraining was 2 years witch include a 9 month of midwifery and 3months of community experience.In 1977, as a result of the decision to prepare multipurpose healthworker& vocationalization of higher secondary education, curriculumwas revised a designed to have 1.5 year of vocationalzed ANMprogramme and six months of general education. The entrancequalification was raised from 7th passed to matriculation passed.Under multipurpose scheme promotional avenue was opened to seniorANMS for undergoing six months promotional training for which coursewas prescribed by
  30. 30.  Training of LHV course continued postindependence. The syllabus preparedand prescribed by INC in 1951.Theentrance qualification wasmatriculation. The duration was twoand a half years which subsequentlyreduced to 2 years.www.drjayeshpatidar.blogspot.inLady Health Visitor Course
  31. 31. General Nursing And Midwifery Course GNM course existed since early years of century. In 1951,syllabus was prescribed by INC. In 1954 a special provision was made for male nurse. First revision of course was done in 1963. Theduration of course was reduced from 4 years to 3.5years. Second revision was done in 1982. The duration ofthe course reduced to 3 years. The Midwifery training of one year duration wasgradually reduced to 9 months and then six months,finally three year integrated programme of GNM wasprescribed in
  32. 32. Post-Basic/Post Certificate Short-Term Courses And DiplomaProgrammes The ultimate aim of all the post-basic/post certificate programme is toimprovement of quality of patient careand promotion of
  33. 33. University-Level Programmes. Basic BSc NursingFirst university programme started just beforeindependence in 1946 at university of Delhi and CMCVellore.INC prescribes the syllabus which has been revisedthree times,the last revision was done in 1981.It wasdone on basis of the 10+3+2 system of generaleducation. At present the BSc Nursing programme which isrecommended by the INC is of four years and havefoundations for future study and specialization
  34. 34. Post Basic BSc Nursing The need for higher training for certificate nurseswas stressed by the Mudaliar Committee in1962. Twoyears post basic certificate BSc(N) programme wasstarted in December 1962. For nurses with diploma in general and midwiferywith minimum of 2 years experience. First started by university of Trivandrum. At present there are many colleges in India offeringPc BSc(N)
  35. 35. Post Basic Nursing by Distance EducationMode. In1985 Indira Gandhi National openuniversity was established. In1992 PostBasic BSc Nursing programme waslaunched, which is three years durationcourse is recognized by
  36. 36. Post- Graduate Education-MScNursing First two years course in masters ofnursing was started at RAK College ofNursing in 1959.and in 1969 in CMCVellore. At present there are manycolleges imparting MSc Nursing degreecourse in different
  37. 37. M.Phil INC felt need for M.Phil programme asearly on 1977,for this purposecommittee was appointed.In 1986 oneyear full time and two years part timeprogramme was started in RAK Collegeof nursing
  38. 38. Ph.D in Nursing Indian nurses were sent abroad for Ph.D programme earlier. From1992 Ph D innursing is also available in India.MAHIis one of the university having
  39. 39. Nurse practitioner in
  40. 40.  RCH (phase I) was launched in October1997 It incorporates the components coveredunder Child survival and safeMotherhood and an addition componentof reproductive tract infection andsexually transmitted
  41. 41. Targets and achievment inRCH 1 (in %)Indicator Baseline Target EstimateIMR 74 60 63Contraceptive rate47.7 60 52Inst delv 35 60 40Childrenimmun52 60 44.6Not usingFP19.5 Less
  42. 42.  National Population Policy 2000 stressed theimportance to bring down maternal mortalityrate. Policy recommends a holistic strategy forbringing about total intersectoral coordinationat grassroot level and involving NGO‟s ,CivilSocieties,Panchayat Raj institutions andwomens
  43. 43. Maternal mortalityCountry RatioIndia 407Sweden 8UK 10Greece 2Sri Lanka 60China 60Thailand
  44. 44. MMR (India)States RatioUP 707Rajasthan 670MP 498Bihar 451Assam
  45. 45. Maternal Health Indicators Antenatal checkups Institutional delivery Delivery by trained
  46. 46. RCH Phase II Begun from 1st April,2005. Focus is to reduce maternal and childmortality with emphasis on rural health care. Fifty percent of PHC‟s and all CHC‟s will bemade operational as 24 hours deliverycentres in a phased manner by 2010. These centres will provide basic emergencyobstetric care and essential newborn
  47. 47. Essential Obstetric care Institutional delivery Skilled attendant at delivery Policy decisions Operationalising emergency
  48. 48. Other Maternal healthinterventions MTP RTI/STD‟s Infection management andenviournment Plan(IMEP)
  49. 49. NEW INITATIVES Training of MBBS doctors in Life SavingAnesthetic skills for emergencyObstetric care Setting up of blood storage in FRU‟s ASHA‟S Janani Sureksha Yojna(JSY)
  50. 50. Scale of assistance perdeliveryCategoryRURAL AREA URBAN AREAMother‟spackageASHA‟sPackageTotalRsMother‟spackageASHA‟sPackageTotalRsLPS 1400 600 2000 1000 200 1200HPS 700 700 600
  51. 51. Independent nursePractitioner 18 month post basic diploma in midwifery Imparts all necessary skill to handle obstetricemergencies Authorised to and can establish independentpractise Course has been pilotes in West Bengal and 2of 4 trainees were assigned to a CHC tomanage obstetric emergencies Eg:Srilankan
  52. 52. Other suggestions with regardto nursing education A dedicated Nursing and Paramedical ManpowerDivision / Unit should be established at theNational and State levels. All medical colleges should be mandated toestablish a College of Nursing offering courses inB.Sc. Nursing, M. Sc. Nursing and Post-BasicDiploma courses in specialty nursing areas. All District Hospitals should be mandated toestablish a school of nursing offering ANM andDiploma in General Nursing and Midwifery, Smaller hospitals in public sector having at least30 OBG beds should be encouraged to start
  53. 53. 1. The NRHM has adopted a set of revised staffing norms for theSub-centres, PHCs and CHCs which will add to the humanresource needs in the rural areas. For the ANM, therequirement has doubled as 2 ANMs have been sanctioned forevery Sub-centres. The Sub-centre will continue to be thecritical facility for the delivery of health care of women andchildren in rural and remote areas where no other facilityexists. The objective of making 2000 facilities as fullyfunctional FRUs will require at least 2000 specialists in OBG,anesthesia and pediatrics (each) and 20,000 staff nurses. Theobjective of making 10,000 PHCs as 24/7 facilities equippedfor institutional delivery implies an additional requirement of30,000 Public Health Nurse Practitioners / General Nurse andMidwives (GNMs). The NRHM provides for additionalmanpower at CHC, PHC & Sub-Center
  54. 54. Standing orders for first aidobstetric care In order to save life of women withobstetric emergencies,ANM is allowedto use the following drugs: Inj. Oxytocin Inj. Magnesium sulphate Misoprestol oral Inj.
  55. 55. Strengthen skills of ANMs in improvingquality of ANC, especially forcounseling. Introduce sticks-based rapid estimation ofhemoglobin and urine examination. Provide mother-baby linked card to all,depicting key messages apart from
  56. 56. INDIAN LEGISLATIVE POLICY Legislative programme:approved byparlimentary affairs department. Scope of bill is determined Acceptance by cabinet Formation of legislative policy Refrence to law department Decision by Minister in charge in consultationwith law Summary to cabinet
  57. 57. Acts in Obstetric Practise MTP Government of India set up the Shantilal ShahCommittee in 1964 to decrease the highmaternalmorbidity and mortality associated withillegalabortions, which, after deliberating on a widerange of evidence over 2 years, recommended abroadening and rationalisation of laws related toabortion in 1966. MTP Bill was introduced in RajyaSabha in 1969, referred to Select Joint CommitteeReview and finally passed as the MTP Act in 1971and implemented in April 1972. Main objective ofMTP Act of India is reduction maternal morbidity dueto illegal unsafe
  58. 58.  According to Section 3, Subsection (2) of the MTPAct, pregnancy may be terminated for the followingindications: a) As a health measure, when there is a danger tothe life or risk to physical or mental health of thewoman including rape and failure of contraception.b) On humanitarian grounds, such as whenpregnancy arises from a sex crime like rape orintercourse with a lunatic woman, etc andc) Eugenic grounds when there is a substantial riskthat the child, if born, would suffer from deformitiesand
  59. 59.  According to Section 3, Subsection (2),for pregnancies up to 12 weeks. thecertification of one qualified doctor issufficient but for pregnancies between12-20 weeks, two doctors must givetheir approval. Termination by medicalmethods of abortion is approved by GOItill 49 days of
  60. 60.  The necessary qualification of a medicalpractitioner registered with the State arebroadly defined in Section 2, Clause (d) of theMTP rules: a) Postgraduate degree or diploma inObstetrics and Gynaecology.b) Registered before commencement of theAct with over 3 years experience in thepractice of Obstetrics and
  61. 61.
  63. 63.  “ An Act to provide for the prohibition of sex selection , before or afterconception, and for regulation of pre-natal diagnostic techniques forthe purpose of detecting genetic abnormalities or metabolic disordersor chromosomal abnormalities or certain congenital malformations orsex-linked disorders and for the prevention of their misuse for sexdetermination leading to female feticide and for matters connectedtherewith or incidental thereto”.This Act may be called “the Pre-Natal Diagnostic Techniques(Regulation and Prevention of Misuse) Amendment Act, 2002.It shall extend to the whole of India except the State Government ofJammu and
  64. 64.  The Pre-Natal Diagnostic Techniques (Regulation andPrevention of Misuse) Act, 1994 is an Act to provide for theregulation of the use of pre-natal diagnostic techniques for thepurpose of the detecting genetic or metabolic disorders orchromosomal abnormalities or certain congenital malformationsor sex-linked disorders and for the prevention of the misuse ofsuch techniques for the purpose of pre-natal sex determinationleading to female foeticide; and for matters connected therewithor incidental thereto. Under Section 2(i) of that Act “pre-nataldiagnostic procedure” means all gynaecological or obstetrical ormedical procedure such as ultrasonography, foetoscopy, takingor removing samples of amniotic fluid, chorionic villi, blood orany tissue of a pregnant woman for being sent to GeneticLaboratory or Genetic Clinic for conducting pre-natal
  65. 65. Monitoring through NRHM Community awareness through ASHAs, integration of the issue in training modules andprogramme and in IEC material, adding information on sex selection to the medicalcurriculum, including indicators on improvement in sex ratiosand birth registration as a part of monitoringtarget/indicators under RCH 2/
  66. 66. The Consumer Protection Act,1986 The aims and objects of the Act asgiven in its Preamble, inter alia are: thebetter protection of the interests of theconsumers and for settlement ofconsumer
  67. 67.  Deficiency in medical services givespatient as a consumer the right to claimcompensation. The consumer Protection Act is a pieceof comprehensive legislation andrecognises six rights of consumers
  68. 68.  Right to safety Right to informed Right to choose Right to be heard Right to seek compensation Right to consumer
  69. 69. Legal issues in maternitypractise Licence to conduct delivery Refer complicated cases appropriately Monitoring of mother and fetus adequately Assist in MTP but can refuse in cases of moraloffense. Proper identification of mother infant pairwith finger prints,foot prints and wasit bandsas per hospital
  70. 70.  Surrogate mother lenting out her uterus forfertilised ovum also possess ethical issuesmainly about monetary compensation. In artificial insemmination maintainconfidentiality about donor and recipient. It is considered unethical if conception isaimed at use of embryo for research
  71. 71. Legal safeguards as a staff Licensure Good Samaritarian Law Standards of care Standing
  72. 72. Woodrow Wilson,AmericanPresidentWe grow great by dreams. All big men aredreamers. They see things in the soft haze of aspring day or in the red fire of a long wintersevening. Some of us let these great dreamsdie, but others nourish and protect them;nurse them through bad days till they bringthem to the sunshine dreams will come
  73. 73. Thank