On job training in a highly reputed NGO like CINI- Child in Need Institute is a great opportunity to learn about community services at the grass-root level. Our training was from 19th December, 2019 to 4th January, 2020. Our course facilitator Miss. Reetushri sen took the session. This file contains summery of my 14 days learning experience and activities.

1. PROJECTREPORT
ON-THE–JOB-TRAINING(19.12.19-4.01.20)
CHILDINNEEDINSTITUTE
Registration no. – 013-1214-0218-17
University Rollno. – 6013-51-0027
College Roll no. – 17/BSCV/270
College- Gokhale Memorial Girls’College

3. ACKNOWLEDGEMENT
Before proceeding further, I Nabanita Das, student of Gokhale memorial girls’
college ( clinical nutrition & dietetics , BSCV part III) would like to extend my
Cordial Gratitude to all the people without whom and whose support and
cooperation my internship would not have been possible,
I would like to express my cordial sense of gratitude and sincere indebtness to:
 Dr, Atashi Karpha, the principal of Gokhale Memorial Girls’ College for
sending me to rain myself in Child In Need Institute (CINI) & continuing
to be my source of encouragement and inspiration.
 Mrs. Pratyasha Aggarwal and Mrs. Paromita Chatterjee for their
unending support and guidance.
 Miss. Reetushri Sen our course co-ordinator at CINI without whom the
entire training would have been incomplete.
 Miss. Chumki Das our Class co-ordinator who helped us in different
matters whenever we needed.
Last but not the least, I would like to thank each and every staff members
and guest lecturers of CINI who had helped me during my training.

4. INTRODUCTION
On job training in a highly reputed NGO like CINI- Child in Need Institute is a
great opportunity to learn about community services at the grass-root level. Our
training was from 19th
December, 2019 to 4th
January, 2020. Our course
facilitator Miss. Reetushri sen took the session. This file contains summery of
my 14 days learning experience and activities.

5. CHILD IN NEED INSTITUTE (CINI)
CINI was founded in 1974 in Kolkata (former Calcutta), West Bengal, India
by a paediatrician Dr Samir Chaudhuri. CINI is a registered non-profit non-
government organisation (NGO) registered under the Societies Registration Act in
India. They work with over 1900 Indian professionals. They are guided by a
Covering Body composed of experienced Indian practitioners, academics and
administrators.
In the early ‘70s, it started treating malnourished and ill children, whose
numbers were rampant in villages and slum areas, with an aim to contrast high child
mortality. Field research backed by medical practice progressively revealed a
fundamental truth about childhood malnutrition. Much before being a health problem,
malnutrition is a social issue. Rooted in a myriad of social economic and cultural
causes, child malnutrition cannot be solved via a mere clinical solution. On the
contrary, it requires a multi-pronged approach, where multidisciplinary teams of
doctors, nurses, nutritionists and social scientists work along with key caregivers,
mainly mothers and other women, to address the determinants of child malnutrition,
disease and death. CINI sought to improve mother and child health by tackling the
vicious cycle of malnutrition and infection to address its root causes, such as poverty,
powerlessness, low status of women, illiteracy, and inadequate health and sanitation
practices. In a historical climate leading to the development of the Primer or Health
Care Movement, CINI mobilised women to improve the health conditions of their
communities. Locally trained child health workers reached out to underserved
communities to promote immunisation, exclusive breastfeeding, early care of
illnesses, and raise awareness on appropriate feeding and care practices, including
growth monitoring and promotion. Training and capacity building, especially of
community mobilisers and frontline workers, grew into a prime focus of CINI, which
set up its training facility for health and development workers, CINI Chetana Training
Centre, in the late 70s. Prevention of malnutrition and promotion of community
health, through the progressive creation of Manila manuals (women's groups) as a
vehicle for local development has remained a major thrust of our programme
activities throughout our history till the present day.

6. CINI MAIN CAMPUS
The Child In Need Institute phase 1 has three main objectives - NRC (Nutrition
Rehabilitation Centre), Thursday clinic, Emergency ward, At first, the mother gets the
baby's name registered at the centre. Thursday clinic is also known as the under-five
clinic since children below five years are treated here. The weight of the baby is
measured and if he/she is malnourished, then he/she is referred to NRC for
admission and treatment. The baby receives 7 meals a day and the mother receives
5 meals a day. The RCH (Reproductive Child Health) clinic deals with reproductive
and child health services. The Thursday clinic of RCH is a special clinic for screening
AIDS, it's treatment and rehabilitation. At the NRC clinic, both mother and baby are
admitted. Previously in it was a 24 hour NRC but now since 2009, it has become a
day-care NRC Thursday clinic and day-care NRC provides Clinical, Nutritional and
Psychological assessments.
CINI Main
Campus
CINI's MISSION - Promote sustainable development in health nutrition
education and protection of the child, adolescent and woman in need.
MILESTONE
•1974 – 1977: Started clinic for the children under 5 years and nutrition
Rehabilitation centre opened an innovation adopted and scaled up by NRHM
(National Rural Health Mission).
• 1978 – 1980: Community based mother and child health and nutrition.
• 1981 – 1983: Training centre started (CCRC) later collaboration with ICDS.

7. •1984 – 1989: CINI Kolkata unit established to work for vulnerable street
children in Kolkata.
• Since 2007: Piloted CFC approach a “ Rights-Based” programming convergence
mode.
APPROACH
• Service delivery to facilitation.
• Vertical to integrated.
• Using area-based programming.
• Working with elected bodies and adding value to government programmes and
policies.
• Empowering women and children, ensuring their participation.
• Moving from needs to a rights-based approach.
SERVICES BY CINI
•Out Patient Department & Thursday Clinic – The Out Patient Department caters
to health problems of children below 6 years. The clinic registers children and
provides them with medicines and conducts minor surgery. The clinic reaches out to
more than 13,000 children in a year. The Thursday clinic provides preventive and
curative services to the children below 6 years and pregnant mothers and acts as a
referral centre both from CINI project and non-project areas. Apart from being
educated in nature, the Clinic also serves as a training exposure unit for trainees
from different backgrounds. The clinic records attendance of over 17.000 children
and 2.500 pregnant women.
•Reproductive Out-Patients - Provides curative services to men & women
suffering from reproductive illness and/or sexually transmitted disease. It also
provides counselling and family planning services and has recorded more than
800 cases.
•Nutrition Rehabilitation Centre – A 12 bedded unit for rehabilitation of children
who have been admitted into the emergency ward with severe malnutrition or are
directive referred by doctors from CINI. The Centre provides awareness on proper
feeding of malnourished children, their care, the preparation of nutritious good and
proper care for the mother.
•Emergency Ward - Equipped with 10 beds for children who have been identified
with complications like acute respiratory illness, diarrhoea or severe malnourished
Children are admitted here along with their mothers who are educated in the proper
care of their child.
•Lactation Management Unit - The unit is devoted to the support and
counselling of mothers with lactation failures. Husbands are also counselled
on the need to ensure adequate nutritional and emotional support to their wife
for successful lactation.

8. •Nutrimix - A low cost supplementary developed by CINI is distributed amongst
malnourished children in the clinic and the mothers are informed about the
ingredients and the preparation.
SOME AWARDS BY CINI
• National award in Child Welfare, 1985, from the President of India.
• The International Prize Liguria Genoa, Italy, 1991.
• The Alan Shawn Feinstein Hunger Award, Brown University, USA, 1993.
• Voluntary Excellence Award by Calcutta Junior Chamber, 1992.
• Special Commendation by Rotary Award for Humanity (India), 2000.
• Award from the Italian Parliament, 2005.
• National award in Child Welfare, 2005, from the President of India.

9. INDEX
DAY DATE CONTENT
1 19.12.2019 CINI’S HISTORY AND ITS
WORKS
2 20.12.2019 LIFE CYCLE APPROACH
RCH,
RMNCH+A,
NHM
MDG,
SDG
ICDS
ROLES OF CDPO,
AW SUPERVISOR &
AWW
3 21.12.2019 ANTENATAL CARE
(ANC)
TIME OF BIRTH
POST NATAL CARE
(PNC)
NEW BORN BABY CARE
HEALTH AND HYGIENE
BREASTFEEDING
POSITIONS
4 23.12.2019 BEHAVIOURAL CHANGE
COMMUNICATION (BCC)
IYCF
5 24.12.2019 MALNUTRITION
GROWTH MONITORING
GROWTH CHART
6 26.12.2019 NRC
ANTHROPOMETRIC
MEASUREMENTS(
MUAC, HEIGHT,
WEIGHT)
BASICS OF
COUNSELLING

10. 7 27.12.2019 SESSION PLAN DESIGN
DIET SURVEY
7 DAYS DIET RECALL
24 HOUR DEIT RECALL
DAY DATE CONTENT
8 28.12.2019 AW CENTRE VISIT
MEASUREMENTS OF
HEIGHT, WEIGHT,
MUAC,HEAD AND
CHEST
CIRCUMFERENCE
9 30.12.2019 CHART AND POSTER
PREPERATION ON
HEALTH TALK TOPIC
10 31.12.2019 COMMUNITY
IDENTIFICATION
SURVEY & 24 HOUR
DIET RECALL OF
COMMUNITY PEOPLE
11 01.12.2020 DELIVER HEALTH TALK
TO DIFFERENT
FAMILIES OF THE
COMMUNITY
PREPARE LOW COST
NUTRITIOUS FOODS:
1.NUTRIMIX PAKORA
2.ALOO KABLI
12 02.12.2020 VISITED THURSDAY
CLINIC
NUTRITIONAL
COUNSELLING
13 03.12.2020 COMMUNICABLE AND
NON COMMUNICABLE
DISEASES
PREPARE CHART ON A
CASE STUDY AND
ANSWER HEALTH

11. REALTED QUESTIONS
14 04.12.2020 PREPARE CHARTS OF
ALL THE TOPICS
TAUGHT GROUPWISE
EVALUATION TEST

12. DAY1
LIFE CYCLE APPROACH
Life cycle is defined as the developmental stages that occur during the
organism’s lifetime. Life cycle approach aims to prevent malnutrition during the
period of intense growth and functional maturation. The critical period of the
human lifecycle is identified as pregnancy, the first two years of life and
adolescence.
We were given a case study (situational analysis) named “Rani Kahini”. There
we saw that a poor rural girl named Rani, who got married at an early age, was
suffering from severe malnutrition and consequently her new born child was
also malnourished. She already had 2 kids by that time, a boy and a girl. She
used to give more preference to her son than her daughter. Thus we also saw
that in the rural society there prevailed gender discrimination where males were
favoured more. At the end of the case, we saw that due to lack of knowledge,
wrong treatment by the doctor, poverty, poor hygiene and sanitation, the new
born child died of acute diarrhoea.
After studying the case properly, one question was given to each of the three
groups to analyze the case and solve it. Our group had to find solutions in order
to prevent the new born child’s death. After solving the questions, we had to
demonstrate the answers by poster presentations.

13. From this analysis on women and children in the community following a life
cycle approach, we learnt about the vicious cycle of malnutrition and how
malnutrition can be prevented in our community. We also learnt that at first, the
nutrition of the mother should be corrected in order to prevent occurrence of
malnutrition in the child

14. DAY2
REPRODUCTIVE AND CHILD HEALTH
(RCH)
The RCH programme was launched in October 1997. Main aim of the
programme is to reduce infant, child and maternal mortality rates.
OBJECTIVES OF THE PROGRAMME IN ITS FIRST PHASE WERE:
 To improve the implementation and management of policy by using a
participatory planning approach and strengthening institutions to
maximize utilization of project resources.
 To improve the quality, coverage and effectiveness of existing family
welfare services.
 To gradually expand the scope and coverage of the family welfare
services to eventually consist of a defined package of essential RCH
services
 Give importance to disadvantaged areas of districts, cities by increasing
the quality and infrastructure of family welfare services
AIMS OF THE RCH PROGRAMME IN ITS SECOND PHASE:
 To expand services to the entire sector of family welfare
 Holding states accountable by involving them in the development of the
programme
 Allowing states to adjust and improved programme features according to
their direct needs
 Improving monitoring and evaluation processes at the district, state and
central level to ensure improved programme implementation

15.  Give performance based funding by recording good performers and
supporting weak performers
 Encourage coordination and convergence within and outside the sector to
maximize use of resourced as well as infrastructural facilities.
RCH PACKAGE OF SERVICES:
FOR MOTHERS: FOR
CHILDREN
FOR
ELIGIBLE
COUPLES:
OTHER NEW
SERVICES(Mostly
for adolescents)
Registration of all
pregnancies
Essential new
born care(0-
28days)
Promoting use
of
contraceptive
methods
Prevention and
management of
RTI/STI
2 doses of TT
immunization
Exclusive
breastfeeding
Safe
MTP(Medical
Termination of
Pregnancy)
services
Adolescent care
100 IFA tablets BCG, DPT,
Polio, Measles
immunization
Nutrition counselling
(mother and
adolescent)
4 antenatal checkups Vitamin a
prophylaxis
Institutional delivery Treatment of
ARI, anaemia
Delivery by trained
personnel
Awareness of
ORT
Post natal checkups
Spacing of births

17. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT
HEALTH (RMNCH+A)
Following the Government of India’s “Call to Action (CAT) Summit” in
February, 2013, the Ministry of Health & Family Welfare launched
Reproductive, Maternal, Newborn Child plus Adolescent Health (RMNCH+A)
to influence the key interventions for reducing maternal and child morbidity and
mortality.
The RMNCH+A strategy is built upon the continuum of care concept and is
holistic in design, encompassing all interventions aimed at reproductive,
maternal, newborn, child, and adolescent health under a broad umbrella, and
focusing on the strategic lifecycle approach.
Key features of RMNCH+A Strategy:
The RMNCH+A strategy approaches include:
 Health systems strengthening (HSS) focusing on infrastructure, human
resources, supply chain management, and referral transport measures.
 Prioritization of high-impact interventions for various lifecycle stages.
 Increasing effectiveness of investments by prioritizing geographical areas
based on evidence.
 Integrated monitoring and accountability through good governance, use
of available data sets, community involvement, and steps to address
grievance.

18. The RMNCH+A strategy provide a strong platform for delivery of services
across the entire continuum of care, ranging from community to various level of
health care system.
THE NATIONAL HEALTH MISSION (NHM)
The National Health Mission (NHM) encompasses its two Sub-Missions, the
National Rural Health Mission (NRHM) and the National Urban Health
Mission (NUHM). The main programmatic components include Health System
Strengthening, Reproductive-Maternal- Neonatal-Child and Adolescent Health
(RMNCH+A), and Communicable and Non-Communicable Diseases. The
NHM envisages achievement of universal access to equitable, affordable &
quality health care services that are accountable and responsive to people’s
needs.
INITIATIVES:
Some of the major initiatives under National Health Mission (NHM) are as
follows:
 Accredited Social Health Activists
 Rogi Kalyan Samiti (Patient Welfare Committee) / Hospital Management
Society
 Untied Grants to Sub-Centres
 Health care contractors

19.  Janani Suraksha Yojana
 National Mobile Medical Units (NMMUs)
 National Ambulance Services
 Janani Shishu Suraksha Karyakram (JSSK)
 Rashtriya Bal Swasthya Karyakram (RBSK)
NATIONAL RURAL HEALTH MISSION
The National Rural Health Mission (NRHM), now under National Health
Mission[1]
is an initiative undertaken by the government of India to address the
health needs of under-served rural areas. Launched on 12 April 2005 by
then Indian Prime Minister Manmohan Singh, the NRHM was initially tasked
with addressing the health needs of 18 states that had been identified as having
weak public health indicators. The Union Cabinet headed by Dr. Manmohan
Singh vide its decision dated 1 May 2013, has approved the launch of National
Urban Health Mission (NUHM) as a Sub-mission of an overarching National
Health Mission (NHM), with National Rural Health Mission (NRHM) being the
other Sub-mission of National Health Mission.
Under the NRHM, the Empowered Action Group (EAG) States as well as North
Eastern States, Jammu and Kashmir and Himachal Pradesh have been given
special focus. The thrust of the mission is on establishing a fully functional,
community owned, decentralized health delivery system with inter-sectoral
convergence at all levels, to ensure simultaneous action on a wide range of
determinants of health such as water, sanitation, education, nutrition, social and
gender equality. Institutional integration within the fragmented health sector
was expected to provide a focus on outcomes, measured against Indian Public
Health Standards for all health facilities. As per the 12th Plan document of
the Planning Commission, the flagship programme of NRHM will be
strengthened under the umbrella of National Health Mission. The focus on
covering rural areas and rural population will continue along with up scaling of
NRHM to include non-communicable diseases and expanding health coverage
to urban areas.

20. NATIONAL URBAN HEALTH MISSION
The National Urban Health Mission (NUHM) as a sub-mission of National
Health Mission (NHM) has been approved by the Cabinet on 1st May 2013.
NUHM envisages to meet health care needs of the urban population with the
focus on urban poor, by making available to them essential primary health care
services and reducing their out of pocket expenses for treatment. This will be
achieved by strengthening the existing health care service delivery system,
targeting the people living in slums and converging with various schemes
relating to wider determinants of health like drinking water, sanitation, school
education, etc. implemented by the Ministries of Urban Development, Housing
& Urban Poverty Alleviation, Human Resource Development and Women &
Child Development.
MILLENNIUM DEVELOPMENT GOALS (MDGs)
The Millennium Development Goals (MDGs) were eight international
development goals for the year 2015 that had been established following
the Millennium Summit of the United Nations in 2000, following the
adoption of the United Nations Millennium Declaration.
 The Eight Millennium Development Goals are:
1. to eradicate extreme poverty and hunger;
2. to achieve universal primary education;
3. to promote gender equality and empower women;
4. to reduce child mortality;
5. to improve maternal health;
6. to combat HIV/AIDS, malaria, and other diseases;
7. to ensure environmental sustainability; and

21. 8. to develop a global partnership for development.

22. SUSTAINABLE DEVELOPMENT GOALS (SDGs)
In September 2015, the General Assembly adopted the 2030 Agenda for
Sustainable Development that includes 17 Sustainable Development Goals
(SDGs). Building on the principle of “leaving no one behind”, the new Agenda
emphasizes a holistic approach to achieving sustainable development for all
 The 17 sustainable development goals (SDGs) to transform our world:
 GOAL 1: No Poverty
 GOAL 2: Zero Hunger
 GOAL 3: Good Health and Well-being
 GOAL 4: Quality Education
 GOAL 5: Gender Equality
 GOAL 6: Clean Water and Sanitation
 GOAL 7: Affordable and Clean Energy
 GOAL 8: Decent Work and Economic Growth
 GOAL 9: Industry, Innovation and Infrastructure
 GOAL 10: Reduced Inequality
 GOAL 11: Sustainable Cities and Communities
 GOAL 12: Responsible Consumption and Production
 GOAL 13: Climate Action
 GOAL 14: Life Below Water
 GOAL 15: Life on Land

23.  GOAL 16: Peace and Justice Strong Institutions
 GOAL 17: Partnerships to achieve the Goal
INTEGRATED CHILD DEVELOPMENT SERVICE (ICDS)
The Integrated Child Development Service (ICDS) Scheme providing for
supplementary nutrition, immunization and pre-school education to the children
is a popular flagship programme of the government. Launched in 1975, it is one
of the world’s largest programmes providing for an integrated package of
services for the holistic development of the child. ICDS is a centrally sponsored
scheme implemented by state governments and union territories. The scheme is
universal covering all the districts of the country.
The Scheme has been renamed as Anganwadi Services.
 OBJECTIVES
 To improve the nutritional and health status of children in the age-group
0-6 years;
 To lay the foundation for proper psychological, physical and social
development of the child;
 To reduce the incidence of mortality, morbidity, malnutrition and school
dropout;
 To achieve effective co-ordination of policy and implementation amongst
the various departments to promote child development; and
 To enhance the capability of the mother to look after the normal health
and nutritional needs of the child through proper nutrition and health
education.

24.  BENEFICIARIES
 Children in the age group of 0-6 years
 Pregnant women and
 Lactating mothers
 SERVICES UNDER ICDS
The ICDS Scheme offers a package of six services, viz.
 Supplementary Nutrition
 Pre-school non-formal education
 Nutrition & health education
 Immunization
 Health check-up and
 Referral services
Three of the six services viz. immunization, health check-up and referral
services are related to health and are provided through National Health Mission
and Public Health Infrastructure. The services are offered at Anganwadi Centres
through Anganwadi Workers (AWWs) and Anganwadi Helpers (AWHS) at
grassroots level.
The delivery of services to the beneficiaries is as follows:
Services Target Group
(i) Supplementary
Nutrition
Children below 6 years,
Pregnant & Lactating Mothers
(P&LM)
(ii) Immunization* Children below 6 years,
Pregnant & Lactating Mothers
(P&LM)

25. iii) Health Check-up* Children below 6 years,
Pregnant & Lactating Mothers
(P&LM)
(iv) Referral Services Children below 6 years,
Pregnant & Lactating Mothers
(P&LM)
v) Pre-School
Education
Children 3-6 years
(vi) Nutrition & Health
Education
Women (15-45 years)
STRUCTURE OF HEALTH CARE SYSTEM IN INDIA
Ministry of Women and Child Development (Central)
Department of Women and Child Development (State level)
District Programme Officer (DPO) – District level
Child Development Project Officer (CDPO) - Block level

26. Supervisor- Panchayat level
Anganwadi Worker (AWW) - Village level

27. ROLES OF CDPO IN ICDS
 Overall in charge of project(ICDS)
 Responsible for planning and implementation of the project
 CDPO is supported by 4-5 supervisors
 Assistant CDPO is required for large ICDS project
ROLES OF SUPERVISOR IN ICDS
 One supervisor is responsible for
workers(AWW)
20,25 and 17 anganwadi
 In rural, urban and tribal areas respectively.
 Guides AWW in planning and organizing delivery of ICDS services
 Provides spot guidance and training as and when requires
 Timely submission of monthly progressive reports to CDPO
 Payment of honorarium to AWW and0 AWH
 Alternative arrangement of AWW and AWH in case of leave
 Finalization of mutually convenient date for monthly meetings
 Informing meeting about special event in circle
 Issuing of manuals from project officers to AWWs
 Carryout other tasks as entrusted to her by CDPO
ROLES OFAWW IN ICDS
 Village mapping and community survey
 Preparation and distribution of supplementary nutrition
 Growth monitoring, promote breastfeeding and counsel on IYCF
 Assist health staff in immunization and health checkups
 Health and nutrition education
 Organizing preschool activities
 Organize awareness campaigns
 Mobilize community and maintain liaison with Panchayat and health
functionaries
 Management of AWC

28.  Maintenance of records, registers and visitor’s book
 Preparation of monthly progress report

29. Day 3
Antenatal care
Prenatal care, also known as antenatal care, is a type of preventive healthcare. Its goal is to
provide regular check-ups that allow doctors or midwives to treat and prevent potential health
problems throughout the course of the pregnancy and to promote healthy lifestyles that benefit
both mother and child. During check-ups, pregnant women receive medical information over
maternal physiological changes in pregnancy, biological changes, and prenatal nutrition
including prenatal vitamins. Recommendations on management and healthy lifestyle changes are
also made during regular check-ups. The availability of routine prenatal care, including prenatal
screening and diagnosis, has played a part in reducing the frequency of maternal death,
miscarriages, birth defects, low birth weight, neonatal infections and other preventable health
problems.
The WHO recommends that pregnant women should all receive four antenatal visits to spot and
treat problems and give immunizations. Although antenatal care is important to improve the
health of both mother and baby, many women do not receive four visits.
There are many ways of changing health systems to help women access antenatal care, such as
new health policies, educating health workers and health service reorganisation. Community
interventions to help people change their behavior can also play a part. Examples of
interventions are media campaigns reaching many people, enabling communities to take control
of their own health, informative-education-communication interventions and financial incentives.
A review looking at these interventions found that one intervention helps improve the number of
women receiving antenatal care. However interventions used together may reduce baby deaths in
pregnancy and early life, lower numbers of low birth weight babies born and improve numbers
of women receiving antenatal care.
Traditional prenatal care in high-income countries generally consists of:
 monthly visits during the first two trimesters (from the 1st week to the 28th week)
 fortnightly visits from the 28th week to the 36th week of pregnancy
 weekly visits after 36th week to the delivery, from the 38th week to the 42nd week
 Assessmentof parental needs and familydynamics
The traditional form of antenatal care has developed from the early 1900s and there is very little
research to suggest that it is the best way of giving antenatal care. Antenatal care can be costly
and uses a lot of staff. The following paragraphs describe research on other forms of antenatal
care, which may reduce the burden on maternity services in all countries.
ANTENATALCARE
 Always begin with Rapid assessment and management (RAM) B3-B7. If the woman has no
emergency or priority signs and hascome for antenatal care, use this sectionfor further care.
 Next use the Pregnancy status and birth plan chart C2 to ask the woman about her present
pregnancy status, history of previous pregancies, and check her for general danger signs. Decide
on an appropriate place of birth for the woman using this chart and prepare the birth and
emergency plan. Thebirthplan should be reviewed during every follow-up visit.

30.  Check all women for pre-eclampsia, anaemia, syphilis and HIV status according to the charts C3-
C6.
 In cases where an abnormal sign is identified (volunteered or observed), use the charts Respond
to observed signs or volunteered problems C7-C11 to classify the condition and identify
appropriate treatment(s).
 Give preventivemeasuresdue C12.
 Develop abirth andemergencyplan C14-C15.
 Advise and counsel on nutrition C13,family planning C16,labour signs,danger signsC15,routine
and follow-up visits C17using Information andCounsellingsheetsM1-M19.
 Recordall positive findings, birth plan, treatments given and the next scheduled visit in the
home-based maternal card/clinic recordingform.
 Assesseligibility of ARTfor HIV-infected womanC19.
 If the woman is HIVinfected, adolescent or hasspecial needs,seeG1-G11H1-H4.
The main objectives of antenatal care are:
1. Maintenance of health of mother during pregnancy
2. Identification of high risk cases and appropriate management
3. Prevent development of complications
4. Decrease maternal and infant mortality and morbidity
5. Remove the stress and worries of the mother regarding the delivery process
6. Teach the mother about child care, nutrition, sanitation and hygiene
7. Advice about family planning
8. Care of under fives accompanying pregnant mothers
Three Stages of maternal health
1. Pregnancy(conceive-Labour Pain)
2. Delivery Period (Labour Pain- Removal of Placenta)
3. Lactation Period (Removal of Placentra-42 days)
Pregnancy
Pregnancy, also known as gestation, is the time during which one or more offspring develops
inside a woman. A multiple pregnancy involves more than one offspring, such as with twins.
Pregnancy can occur by sexual intercourse or assisted reproductive technology. A pregnancy
may end in a live birth, abortion, or miscarriage, though access to safe abortion care varies
globally. Childbirth typically occurs around 40 weeks from the start of the last menstrual period
(LMP). This is just over nine months, where each month averages 31 days. When measured from
fertilization it is about 38 weeks. An embryo is the developing offspring during the first eight
weeks following fertilization, after which, the term fetus is used until birth. Symptoms of early
pregnancy may include missed periods, tender breasts, nausea and vomiting, hunger, and
frequent urination. Pregnancy may be confirmed with a pregnancy test.
Detection of Pregnancy
Pregnancy is confirmed with a pregnancy test. A pregnancy test can be done on either urine or blood.
Pregnancy tests find the presence of human chorionic gonadotropin hormone (hCG). This is a hormone
made by the placenta about 10 days after fertilization. Levels of the hCGhormone approximately double
every two days during the first 60 days of pregnancy. Pregnancy tests that use the woman's blood are
done by ahealthcare provider usually to get avery early diagnosis of pregnancy or to confirm an at-

31. home pregnancy test. Blood tests are very accurate and can find pregnancy by the second week after
conception.
Complications of pregnancy
Complications of pregnancy are health problems that are related to pregnancy. Complications
that occur primarily during childbirth are termed obstetric labor complications, and problems that
occur primarily after childbirth are termed puerperal disorders. Severe complications of
pregnancy, childbirth, and the puerperium are present in 1.6% of mothers in the US and in 1.5%
of mothers in Canada. In the immediate postpartum period (puerperium), 87% to 94% of
pregnant individuals report at least one health problem. Long-term health problems (persisting
after six months postpartum) are reported by 31% of pregnant individuals.
The following complications are
 1 Maternal problems
o 1.1 Gestational diabetes
o 1.2 Hyperemesisgravidarum
o 1.3 Pelvic girdle pain
o 1.4 High blood pressure
o 1.5 Deepvein thrombosis
o 1.6 Anemia
o 1.7 Infection
o 1.8 Peripartum cardiomyopathy
o 1.9 Hypothyroidism
 2 Fetal and placental problems
o 2.1 Ectopic pregnancy implantation ofembryo outside the uterus
o 2.2 Miscarriage
o 2.3 Placentalabruption
o 2.4 Placentapraevia
o 2.5 Placentaaccreta
o 2.6 Multiple pregnancies
o 2.7 Vertically transmitted infection
o 2.8 Intrauterine bleeding
The danger signs in pregnancy
Most women go through pregnancy with some uncomfortable symptoms but no serious
problems. Normal discomforts of pregnancy can include nausea (especially in the first 3
months), heartburn, a need to urinate often, backache, breast tenderness and swelling, and
tiredness.
There are some symptoms that may mean danger for you or the baby. Being aware of these
danger signs can help you know when you may need special care from your healthcare provider.
Contact your healthcare provider right away if you have any of the following symptoms before
the 37th week of pregnancy:
 Pain, pressure, or cramping in your belly
 Contractions that happen more than 4 times an hour or are less than 15 minutes apart
 Leaking of fluid from the vagina

32. Also call your provider right away if you have:
 Vaginal bleeding
 A lot of nausea and vomiting
 A temperature over 100°F (37.8°C)
 Very bad headache or a headache that lasts for several days
 New problems with your vision
 Less movement and kicking by the baby
 Sudden weight gain (3 to 5 pounds within 5 to 7 days) with a lot of swelling of your feet,
ankles, face, or hands
 Seizures
You should also call your provider if you have:
 Blood in your urine or burning and pain when you urinate
 Diarrhea that doesn’t go away
 Vaginal discharge with a bad odor, irritation, or itching
Care during pregnancy
1. See your doctor or midwife as soon as possible. As soon as you find out you're pregnant,
get yourself registered for antenatal care. ...
2. Eat well. ...
3. Take a supplement. ...
4. Be careful about food hygiene. ...
5. Exercise regularly. ...
6. Begin doing pelvic floor exercises. ...
7. Cut out alcohol. ...
8. Cut back on caffeine.
9. Stop smoking.
Postnatal care
Introduction
Postnatal care (PNC) is the care given to the mother and her newborn baby immediately after
the birth and for the first six weeks of life (Figure 1.1). This period marks the establishment of a
new phase of family life for women and their partners and the beginning of the lifelong health
record for newborn babies (or neonates — a term often used by doctors, nurses and midwives).
Importance of Postnatal Care :
The time when effective postnatal care can make the most difference to the health and life
chances of mothers and newborns is in the early neonatal period, the time just after the delivery
and through the first seven days of life. However, the whole of the neonatal period, from birth
to the 28th day after the birth, is a time of increased risk. Deaths during the first 28 days of
babies who were born alive is reported by all countries in the world as the neonatal mortality
rate (the number of babies who die in the first 28 days) per 1,000 live births. Similarly, reports
of maternal mortality include deaths of women from complications associated with postnatal
problems, not just problems arising during the birth. Both these rates are important indicators of
the effectiveness of postnatal care.

33. This high risk period is also the time with the lowest coverage of maternal and child health care
in Ethiopia. This is the second reason why you need to focus more attention on postnatal care.
Global estimates of maternal and newborn mortality in the first seven days after the birth.
Deathsafter deliveryFirst24 hours(%)Firstsevendays (%)
Maternal mortality 45 65
Neonatalmortality 50 75
For some life-threatening maternal and newborn conditions, effective postnatal care is either
given in the first few hours and days, or it will happen too late. The earlier these clinical
conditions are detected, the more effectively they can be managed; the quicker they are referred
for specialised treatment, the better the outcomes will be. Unfortunately, most of these
interventions are highly time-dependant in order to be effective. You should keep this in mind
while providing care to mothers and their babies in the first few days of postnatal life.
Causes of mothers and newborns in the postnatal period death
The main purpose of providing optimal postnatal care is to avert both maternal and neonatal
death, as well as long-term complications. To be effective you therefore need to know the major
causes of death in the postnatal period, so that you can provide quality and timely postnatal care
at the domestic and Health Post level.
Women and newborns at high risk in the postnatal period :
The most critical period for complications in the postnatal mother arising from bleeding (post-
partum haemorrhage) is in the first 4-6 hours after delivery, due to excessive blood loss from the
site where the placenta was attached to the mother’s uterus, or from rupture of the uterus during
labour and delivery. Haemorrhage can also threaten the baby’s life if it occurs before delivery
and the baby is starved of oxygen and nutrients.
Both the mother and the baby are also at high risk of developing other complications if the
physiological adjustments that take place in their bodies after the birth do not occur properly.
This can result in loss of function or interruption of essential supplies of oxygen and nutrients
needed to sustain life.
Physiological changes in the postnatal mother
During labour and delivery, there is inevitably some loss of blood and other body fluids (for
example, from vomiting and sweating), which is tolerable by the majority of women. Some
degree of this is normal. Additionally, most women in labour remain for long hours without
taking food or sufficient fluids, which can leave them dehydrated. Unless they are rehydrated
quickly after the birth, physiological complications become more likely.
During pregnancy, activity in almost all the mother’s body systems changes, including the heart,
lungs, blood volume and blood contents, reproductive system, breasts, immune system and
hormones. In the postnatal period, all these dynamic body systems have to adjust from the
pregnant state back to the pre-pregnant state, and there is a potential risk of complications as
these adjustments occur. Common examples are breast infections and deep vein thrombosis

34. (blood clots in the veins of the legs).The period in which these physiological adjustments take
place in the postnatal mother is called the puerperium.
Additionally, labour is a painful experience for most women, particularly for those giving birth
for the first time. There is also tension and anxiety about the outcome of labour and delivery.
Having a baby is a joy but it can also be a source of worry. Women in the postnatal period are
often coping with stressful conditions and thus they need sustained psychological support.
Follow-up after immediate postnatal care
During the first postnatal visit, you should also remember to:
 Counsel the mother and her husband/partner about family planning, immunization, and breast
feeding, asyou willlearn later in this Module.
 Make an appointment for her to come to your Health Post or visit her at home after three days,
six daysand six weeks(Figure1.2) if everything is progressingnormally.
 Make an additional appointment to visit her at home after two days if there are any
complications which have not resulted in referral, or if the baby was pre-term, low birth weight
or suffers from low bodytemperature.
Community mobilisation for postnatal care
Community mobilisation is defined as an action stimulated by a community, or by others,
which are planned, carried out and evaluated by community members, organisations or groups,
to solve community health problems. In this study session, the focus is on health problems
arising during the postnatal period. Community mobilisation is a continuous and cumulative
process of communication, education and organisation to build leadership and implementation
capacity.
Methods for communitymobilisation
Posters: Well-designed posters, placed and located in the right place can facilitate messages to
keep reminding people about the issue of concern.
Letter writing: This is one way of delivering health messages to literate members of the
community. It gives the exact message and can be kept for future reference.
Illustrated leaflets: Pictures are a good way of getting the message to people whose level of
literacy is insufficient to understand letters .
Home visiting: This is the best way of mobilising the community, because you can be sure that
the message has been delivered.
Community mobilisation is based on a high level of community participation, which occurs
when community members taking part in identification of problems and needs, and then plan,
implement, monitor and evaluate community activities to solve the identified problem.
The fundamental principle that you always need to remember is that you are not there to
‘enforce’ community participation. Your role is to explore, to learn from community wisdom,
and to educate and persuade community members to bring about the necessary changes — in this
case to improve postnatal outcomes. The final word and the final decision always belong to the
community.

35. Importance of community participation :
When people are involved and participate in an activity, they develop a sense of ownership and
responsibility, which helps to sustain initiatives, activities and programmes. It also has the
following benefits:
 Increased availability of resources ascommunity memberswillingly contribute time and
resources to what they consider to be their own initiatives and activities.
 Asenseof unity among community members.
 Increasing confidence asthe successesof their contributions areregistered.
 People are empowered to exercise their skills, talents and develop their potential.
 Behaviour changewill be quicker andeasier.
 Controlling harmful traditional practices becomeseasier.
Benefits of Postnatal care :
 Visit individual community leaders, TBAsand traditional healers to engagetheirsupport.
 Organiseorientation meetings forall opinion leaders and gatekeepers.
 With community leaders and TBAs, plan and organise community meetings to educate
community members about postnatalcare.
 Carryout home visits to teach parents and caregivers about postnatal care (Figure 1.4).
 Distribute information, education and communication (IEC)materials to community leaders and
community members.
 Facilitate the healing process. During delivery, the mother's body may go through shock
due to the process of childbirth. ...
 Mental wellness. ...
 Pain Management. ...
 Boosts milk production. ...
 Hot compresses. ...
 Nutrition. ...
 Tummy wraps.
Health Check up
After Delivery health check up should be done 3rd
,7th
,14th
,21st
,28th
,42nd
days
Newborn care
Taking a newborn care class during pregnancy can prepare caregivers for the real thing. But
feeding and diapering a baby doll isn't quite the same. During the stay in a hospital or birthing
center, clinicians and nurses help with basic baby care. These health providers will demonstrate
basic infant care. Newborn care basics include:
 Immunization should beprovided.
 Handling anewborn, including supporting the baby'sneck
 Bathing
 Dressing
 Swaddling
 Feeding and burping
 Cleaning the umbilical cord
 Caring for ahealing circumcision
 Using abulb syringe to clear the baby'snasal passages

36.  Takinganewborn's temperature
 Tipsfor soothing thebaby
Before leaving the hospital, ask about home visits by a nurse or health care worker. Many new
parents appreciate somebody checking in with them and their baby a few days after coming
home. If breastfeeding, a mother can ask whether a lactation consultant visit in the home to
provide follow-up support, as well as providing other resources in the community, such as peer
support groups.
Caring for a newborn also includes the health screening of the newborn, most of the times this
occurs in the hospital or pediatrician's office shortly after birth. Every state screens babies for
more than two dozen disorders. Early detection can help treat the disorder.
The steps to keep the newborn warm are called the warm chain.
1. Warm the delivery room.
2. Immediate drying.
3. Skin-to-skin contact at birth.
4. Breastfeeding.
5. Bathing and weighing postponed.
6. Appropriate clothing/bedding.
7. Mother and baby together.
8. Warm transportation for a baby that needs referral.
Handling a Newborn
If you haven't spent a lot of time around newborns, their fragility may be intimidating. Here are a
few basics to remember:
 Wash your hands (or use a hand sanitizer) before handling your baby. Newborns don't have a
strong immune system yet, so they're at risk for infection. Make sure that everyone who
handles your baby hasclean hands.
 Support your baby's head and neck. Cradle the head when carrying your baby and support the
head when carrying the baby upright or when you lay your baby down.
 Never shake your newborn, whether in play or in frustration. Shaking can cause bleeding in the
brain and even death. If you need to wake your infant, don't do it by shaking — instead, tickle
your baby's feet orblow gently on acheek.
 Make sure your babyissecurelyfastened into the carrier, stroller, or car seat. Limit any activity
that could be too roughor bouncy.
 Remember that your newborn is not ready for rough play, such as being jiggled on the knee or
thrown in theair

37. Breastfeedingpositions
Formost mums, breastfeeding is alearned skill. Mothers may therefore require additional breastfeeding
support when learning how to breastfeed. In particular, mothers may require assistance with learning
how to position and attach the baby to ensure they are able to feed the baby comfortably and that the
baby is able to successfully transfer milk. There are many breastfeeding positions that may work for
each mother. An important consideration or breastfeeding tip for the mum is that sheshould always
feel comfortable. In general,the infant should be positioned sothat they are facingthe mum's body and
their head, shoulders and hips are in alignment. Someof the most commonly used positions include the
cradle position, cross-cradle position, clutch positionand side-lying position.
Cradle position
The cradle hold is the most common breastfeeding position.
The mum's arm supports the baby at the breast. The baby’s head is cradled near her elbow, and
her arm supports the infant along the back and neck. The mother and baby should be chest to
chest.
Cross-cradle position

38. The cross-cradle position uses the opposite arm (to the cradle position) to support the infant,
with the back of the baby's head and neck being held in the mother's hand. Her other hand is
able to support and shape the breast if required.
In this position the mum can guide the baby easily to the breast when they are ready to latch on.
Clutch position
The baby is positioned at the mother’s side, with their body and feet tucked under the mum's
arm. The baby’s head is held in the mum's hand. The mum’s arm may also rest on a pillow with
this hold.
This position may be advantageous for mums who have undergone a caesarean section, since it
places no or limited weight on the mum’s chest and abdomen area.
It may also work for low-birth-weight babies or babies that have trouble latching, since their
head is fully supported.
Side-lying position
The mum lies on her side and faces the baby. The baby's mouth is in line with the nipple.
The mum may also use a pillow for back and neck support.
This position may also be advantageous for mums who have undergone a caesarean section,
since it places no or limited weight on the mum’s chest and abdomen area.

39. Familyplanning
TheWorld Health Organization definition is this: “Familyplanningallows individuals and couples to
anticipate and attain their desired number of children and the spacingand timing of their births. ...
Familyplanningprevents about one-third of pregnancy-related deaths,aswell as44%of neonatal
deaths.
 Purposefor Family Planning
Somefamilyplanningmethods, such ascondoms, help prevent the transmission of HIVand other
sexually transmitted infections. Familyplanning/ contraception reduces the need for abortion,
especially unsafe abortion. Familyplanningreinforces people's rights to determine the numberand
spacingof theirchildren.
Methods of familyplanning:
 long-acting reversible contraception, such as the implant or intra uterine device (IUD)
 hormonal contraception, such the pill or the Depo Provera injection.
 barrier methods, such as condoms.
 emergency contraception.
 fertility awareness.
Benefits of family planning / contraception
Promotion of family planning – and ensuring access to preferred contraceptive methods for
women and couples – is essential to securing the well-being and autonomy of women, while
supporting the health and development of communities.
Preventing pregnancy-related health risks in women

40. A woman’s ability to choose if and when to become pregnant has a direct impact on her health
and well-being. Family planning allows spacing of pregnancies and can delay pregnancies in
young women at increased risk of health problems and death from early childbearing. It prevents
unintended pregnancies, including those of older women who face increased risks related to
pregnancy. Family planning enables women who wish to limit the size of their families to do so.
Evidence suggests that women who have more than 4 children are at increased risk of maternal
mortality.
By reducing rates of unintended pregnancies, family planning also reduces the need for unsafe
abortion.
Reducing infant mortality
Family planning can prevent closely spaced and ill-timed pregnancies and births, which
contribute to some of the world’s highest infant mortality rates. Infants of mothers who die as a
result of giving birth also have a greater risk of death and poor health.
Helping to prevent HIV/AIDS
Family planning reduces the risk of unintended pregnancies among women living with HIV,
resulting in fewer infected babies and orphans. In addition, male and female condoms provide
dual protection against unintended pregnancies and against STIs including HIV.
Empowering people and enhancing education
Family planning enables people to make informed choices about their sexual and reproductive
health. Family planning represents an opportunity for women to pursue additional education and
participate in public life, including paid employment in non-family organizations. Additionally,
having smaller families allows parents to invest more in each child. Children with fewer siblings
tend to stay in school longer than those with many siblings.
Reducing adolescent pregnancies
Pregnant adolescents are more likely to have preterm or low birth-weight babies. Babies born to
adolescents have higher rates of neonatal mortality. Many adolescent girls who become pregnant
have to leave school. This has long-term implications for them as individuals, their families and
communities.
Slowing population growth
Family planning is key to slowing unsustainable population growth and the resulting negative
impacts on the economy, environment, and national and regional development efforts.

41. To learn about adolescence health and hygiene
The teenage years are also called adolescence. Adolescence is a time for growth spurts and
puberty changes. An adolescent may grow several inches in several months followed by a period
of very slow growth, then have another growth spurt. Changes with puberty (sexual maturation)
may happen gradually or several signs may become visible at the same time.
There is a great amount of variation in the rate of changes that may happen. Some teenagers may
experience these signs of maturity sooner or later than others
Adolescentdevelopment
During adolescence, children develop the ability to:
 Understand abstract ideas. Theseinclude graspinghigher math concepts,and developing moral
philosophies, including rights andprivileges.
 Establish and maintain satisfying relationships. Adolescents will learn to share intimacy without
feeling worried orinhibited.
 Move toward amore mature senseof themselves and their purpose.
 Question old values without losing theiridentity.
Puberty-Related Growth Spurts
 In girls, sexual development starts between the ages of 8 and 13, and have a growth spurt
between the ages of 10 and 14
 In boys, sexual development starts between the ages of 10 and 13, and continue to grow
until they're around 16.
Changes in Girls
These characteristics describe the sequence of events as girls go through puberty:
 There is an increase in the rate of growth of height.
 The size of uterus and vagina increases.
 There is an increase in the size of breast
 Pubic hair begins to appear, usually within 6 to 12 months after the start of breast
development.
 The rate of growth in height reaches its peak in about 2 years after puberty
Once girls start to menstruate, they usually grow about 1 or 2 more inches, reaching their final
adult height by about age 14 or 15 years (younger or older depending on when puberty began).
Changes in Boys
Boys tend to show the first physical changes of puberty between the ages of 10 and 16 years.
They tend to grow quickly between ages 12 and 15. The growth spurt of boys on average is
about 2 years later than that of girls. By age 16, most boys stop growing, but their muscles will
continue to develop.
Characteristics of puberty in boys include:

42.  The size of penis and testicles increase.
 Pubic hair appears, followed by underarm and facial hair.
 The voice deepens and may sometimes crack or break.
 The larynx cartilage or Adam's apple gets bigger.
 Testicles begin to produce sperm.
Healthy diet can help teenager to look good and stay healthy:
Eating breakfast: Skipping breakfast does not help in losing weight, because essential nutrients
might be missed out. A healthy breakfast is an important part of a balanced diet and provides
some of the vitamins and minerals required for good health. Whole grain cereal with fruit sliced
over the top is a tasty and healthy way to start the day.
Aim to eat fruits and vegetables a day: Fruits and vegetables are sources of most of the
vitamins and minerals which is essential for the body. Fresh fruit juice, smoothies and vegetables
can help in balanced diet.
At snack time, substitute foods that are high in saturated fat or sugars for healthier
choices: Foods high in saturated fat include pies, processed meats such as sausages and bacon,
biscuits and crisps. Foods high in added sugars include cakes and pastries, sweets, and chocolate.
Too much saturated fat can also cause high cholesterol.
Drink enough fluids: One should aim to drink at least six to eight glasses of fluids a day, water,
unsweetened fruit juices (diluted with water) and milk are all healthy choices.
Eating healthy food: Foods such as whole meal bread, beans, wholegrain breakfast cereals,
fruit and vegetables. Such kind of foods are high in fibre are bulky and help us feel full for
longer time.
Being Underweight: Not eating a balanced diet or restricting food intake can lead to deficiency
of important nutrients in the body. This can lead to weight loss. Being underweight can cause
health problems, so if you're underweight it's important to gain weight but in a healthy way.
Being Overweight: Foods rich in fat and sugar are high in calories, or eating too many calories
can lead to weight gain. Try to eat lesser foods that are high in fat and sugar, such as swapping to
low or no sugar fizzy drinks. A healthy balanced diet will provide you with all the nutrients your
body needs
There any national health programme in India for adolescents
The government of India has a comprehensive package for meeting the multiple health needs of
the adolescents and offers a roadmap for programmes and priorities that aim to address
adolescent health ARSH (Adoloscents reproductive and sexual health) is included as a part of
RMNCH+A. The National ARSH strategy provides a framework for a range of sexual and
reproductive health services to be provided to the adolescents. The strategy incorporates a core
package of services including preventive, promotive, curative and counseling services. Effective
implementation of policies and programmes has progressed from the past few years and has lead
to strengthening of Adolescent Friendly clinics and subsequently the outreach programmes.
Various programmes for adolescents are:
 Kishori ShaktiYojna
 Balika Samridhi Yojana
 Rajiv Gandhi Schemefor Empowerment of AdolescentGirls
 SarvaShiksha Abhiyan

43. School health and hygiene programme:
The School Health Programme was launched to address the health needs of school going
children and adolescents in the 6-18 year age groups in the Government and Government aided
schools. The programme entails biannual health screening and early management of disease,
disability and common deficiency and linkages with secondary and tertiary health facilities as
required..
Weekly Iron folic acid supplementation (WIFS):
Weekly supplementation of 100mg elemental Iron and 500ug Folic Acid (IFA) is effective in
decreasing incidence and prevalence ofanemia in adolescents, MOHFW has launched the
Weekly Iron and Folic Acid Supplementation (WIFS) Programme for school going adolescent
girls and boys and for out of school adolescent girls. The Programme envisages administration of
supervised weekly IFA Supplementation and biannual deworming tablets to approximately 13
crore rural and urban adolescents through the platform of Government aided and municipal
school and anganwadi Kendra and combat the intergenerational cycle of anemia.
Menstrual hygiene scheme:
The Ministry of Health and Family Welfare (MOHFW) has introduced a scheme for promotion
of menstrual hygiene among adolescent girls in the age group of 10-19 year in rural areas. The
pilot is being implemented in 152 districts across 20 States in the country, wherein supply in 105
districts is through central procurement with quality assurance guidelines is through local Self
Help Groups. The sanitary napkin packs (containing 6 pieces each) is branded as ‘Free days’.

44. DA
Y4:
Communication
Communications is fundamental to the existence and survival of humans as well as to an organization. It is
a process of creating and sharing ideas, information, views, facts, feelings, etc. among the people to reach
acommon understanding. Communication is the key tothe Directing function of
management.Communication skills are vital to ahealthy, efficient workplace. Often categorized asa“soft
skill” or interpersonal skill, communication is the act of sharing information from one person to another
personor group of people. There are many different ways to communicate, eachof which play an
important role in sharinginformation.
Typesof communication
Verbal
Verbal communication is the useof languageto transfer information through speakingor sign language.It
is one of the most common types, often usedduring presentations, video conferences and phone calls,
meetings and one-on-one conversations. Verbal communication is important becauseit is efficient. It can
be helpful to support verbal communication with both nonverbal and written communication.
Nonverbal
Nonverbal communication is the useof body language,gestures and facial expressions to convey
information to others. It can be used both intentionally and unintentionally. For example, you might smile
unintentionally when you hear apleasingor enjoyable idea or piece of information.Nonverbal
communication is helpful when trying to understand others’thoughts andfeelings.
Written
Written communication is the act of writing, typing or printing symbolslike letters andnumbers to
convey information. It is helpful becauseit provides arecord of information for reference. Writing is
commonly usedtoshareinformation through books, pamphlets, blogs, letters, memosand more. Emails
and chats are acommon form of written communication in the workplace.
Visual
Visualcommunication is the act of usingphotographs, art, drawings, sketches,charts andgraphsto
convey information. Visualsare often usedasan aid during presentations to provide helpful context
alongside written and/or verbal communication. Becausepeople havedifferent learning styles,visual
communication might be more helpful for sometoconsumeideas andinformation.
Stepsof Communication
R- Rapport
A–Ask
L–Listen
P– Praise
A–Advice
C– Checkingunderstanding

45. Communications Process
Communications is a continuous process which mainly involves three elements viz. sender,
message, and receiver. The elements involved in the communication process are explained
below in detail:
1. Sender
Thesenderor the communicator generatesthe messageand conveysit to the receiver. Heis the source
and the one who starts thecommunication
2. Message
It is the idea, information, view, fact, feeling, etc. that is generated by the senderand is then intended to
be communicated further.
3. Encoding
Themessagegenerated by the senderis encodedsymbolically suchasin the form of words, pictures,
gestures, etc. before itis being conveyed.
4. Media
It is the manner in which the encoded message is transmitted. The message may be transmitted orally or
in writing. The medium of communication includes telephone, internet, post, fax, e-mail, etc. The choice
of medium is decided by thesender.
5. Decoding
It is the process of converting the symbols encoded by the sender. After decoding the message is received
by the receiver.
6. Receiver
Heis the person who is last in the chain and for whom the messagewassent by the sender. Oncethe
receiver receives the messageand understands it in proper perspective and actsaccording to the
message,only then the purpose of communication issuccessful.
7. Feedback
Oncethe receiver confirms to the senderthat he hasreceived the messageand understood it,the
processof communication iscomplete.
8. Noise
It refers to any obstruction that is causedby the sender, messageor receiver during the process of
communication. For example, bad telephone connection, faulty encoding, faultydecoding, inattentive
receiver, poor understanding of message due to prejudice or inappropriate gestures, etc.

46. Importanceof communication
Weusecommunication every dayin nearly every environment, including in the workplace. Whether you
give aslight head nod in agreement or present information to alarge group, communicationis absolutely
necessarywhen building relationships, sharing ideas,delegating responsibilities, managingateam and
much more.
Learning and developing good communication skills canhelp you succeedin your career, make you a
competitive job candidate and build your network. While it takes time andpractice, communication and
interpersonal skills are certainly able to be bothincreased and refined.
F
ACTORSAFFECTINGCOMMUNICATION
Anumber of factors which maydisrupt the communication process and affect the overall understanding
and interpretaion of what is communicated are:
1. Status/ Role
2. Cultural differences.
3. Choiceof communication channel.
4. Lengthof communication.
5. Useof language.
6. Individual Perceptions / Attitudes / Personalities .
7. Known or Unknown Receiver.
BARRIERSTOCOMMUNICATION
(1) SEMANTICBARRIERS

47. Thereis always apossibility of misunderstanding the feelings of the senderof the messageor getting a
wrong meaning of it. Thewords, signs,and figures usedin the communication are explained by the
receiver in the light of his experience which creates doubtful situations. This happensbecausethe
information is not sent in simple language..The semantic barriers are as:
(i) Badly Expressed Message
(ii) Symbols or Words with DifferentMeanings
(iii) FaultyTranslation
(iv) UnclarifiedAssumptions
(v) TechnicalJargon
(vi) BodyLanguageandGesture Decoding
(2) PSYCHOLOGICALBARRIERS
Theimportance of communication dependson the mental condition of both the parties. Amentally
disturbed party canbe ahindrance in communication. Following are the emotional barriers in theway of
communication:
(i)
(ii)
(iii)
(iv)
PrematureEvaluation
Lackof Attention
Lossby Transmissionand Poor Retention
Distrust
(3) ORGANIZA
TIONALBARRIERS:
Organisational structure greatly affects the capability of the employees asfar asthe communication is
concerned. Somemajor organisational hindrances in the way of communication are the following:
(i) OrganisationalPolicies:
(ii) Rulesand Regulations
(iii) Status
(iv) Complexity in OrganisationalStructure
(v) Organizationalfacilities
(4) PERSONALBARRIERS
Thebarriers which are directly connected with the senderand the receiver. Theyare called personal
barriers. From the point of view of convenience, they havebeen divided into two parts:
(a) Barriers Relatedto Superiors: Thesebarriers are asfollows:
(i) Fearof ChallengeofAuthority
(ii) Lackof Confidencein Subordinates
(b) Barriers Related to Subordinates
(i) Unwillingness to Communicate
(ii) Lackof ProperIncentive
Behaviorchangecommunication
BCC" or "Communication for Development (C4D)" is an interactive process of any intervention with
individuals, group or community (as integrated with an overall program) to develop communication
strategies to promote positive behaviors which are appropriate to their settings and there by solve world's

48. most pressing health problems. This in turn provides a supportive environment which will enable people to
initiate, sustain and maintain positive and desirable behavior outcomes.
SBCC is the strategic use of communication to promote positive health outcomes, based on proven
theories and models of behavior change. SBCC employs a systematic process beginning with formative
research and behavior analysis, followed by communication planning, implementation, and monitoring and
evaluation. Audiences are carefully segmented, messages and materials are pre-tested, and mass media
(which include radio, television, billboards, print material, internet), interpersonal channels (such as client-
provider interaction, group presentations) and community mobilisation are used to achieve defined
behavioral objectives.
BCC should not be confused with behavior modification, a term with specific meaning in a clinical
psychiatry setting.
Steps
SBCC is the comprehensive process in which one passes through the stages:
Unaware > Aware > Concerned > Knowledgeable > Motivated to change > Practicing trial behavior
change
> Sustained behavior change
It involves the following steps:
1. State programgoals
2. Involve stakeholders
3. Identify targetpopulations
4. Conduct formative BCCassessments
5. Segmenttarget populations
6. Define behavior changeobjectives
7. Define SBCCstrategy & monitoring and evaluationplan
8. Develop communication products
9. Pretest
10. Implement andmonitor
11. Evaluate
12. Analyze feedback and revise
Steps
SBCC is the comprehensive process in which one passes through the stages:
Unaware > Aware > Concerned > Knowledgeable > Motivated to change > Practicing trial behavior
change
> Sustained behavior change
BCCin classroom practices
It involves the following steps:
1. State programgoals
2. Involve stakeholders
3. Identify targetpopulations
4. Conduct formative BCCassessments
5. Segmenttarget populations

49. 6. Define behavior changeobjectives
7. Define SBCCstrategy & monitoring and evaluationplan
8. Develop communication products
9. Pretest
10. Implement andmonitor
11. Evaluate
12. Analyze feedback and revise
Strategies While Developing BCC Messages:
BENIFITSOFBCC
Increasein knowledge and attitude of the people. BCChelps to trigger and stimulate people for adopting positive
behavioral approaches. BCCpromotes appropriate and essential attitude change.AsBCCstrategies and messages
are tailored for specific target groups,these strategies are efficient and effective
IMPORTANCEOFBCC.
 Increasein knowledge and attitude of the people
 BCChelps to trigger and stimulate people for adopting positive behavioral approaches
 BCCpromotes appropriate and essential attitudechange
 AsBCCstrategies and messagesare tailored for specific target groups,these strategies are efficient and
effective.
 BCCapproaches are more sustainable andacceptable
 BCChelps to increase learning andskills
 It improve aptitudes and feeling ofself-adequacy

50. Apart fromthese,importance of BCCat differentlevelsare:
1. Atindividual-level
 BCChelps in learning, mindfulness, convictions, and sentiments about wellbeing practices. It plays a
significant role in deciding wellbeingconduct.
2. Atcommunity-level
 BCCapproachstimulates community to take ownership towards the approach. Additionally, it will also help
the community to replicate the positive practices in bigger level.
3. At nationallevel
 BCCwill play a significant role in lobbying & advocacyof certain practices. These approaches will support
and encourage government and other stakeholders to bring apositive whim among all the citizens for
adopting positive behavioralpractices.
INFANTANDYOUNGCHILDFEEDING
Defining Infant andYoungChildFeedingInfant andYoungChildFeeding(IYCF)is aset of well-known and
common recommendations for appropriate feeding of new-born andchildren under two years of age.
IYCFincludes the following carepractices:
EarlyInitiation of Breastfeeding
It meansbreastfeeding all normal newborns (including those born by caesareansection) asearly as
possible after birth, ideally within first hour. Colostrum ,the milk secreted in the first 2-3 days, must not

51. be discarded but should be fed to newborn asit contains high concentration of protective
immunoglobulins and cells. No pre-lacteal fluid should be given tothe newborn. Exclusive breastfeeding
for the first 6 months meansthat an infant receives only breast milk from his or her mother or awet
nurse, or expressedbreast milk, andno other liquids or solids, not even water. Theonly exceptions
include administration of oral rehydration solution, oral vaccines, vitamins, minerals supplements or
medicines. .
Complementaryfeeding
It meanscomplementing solid/semi-solid food with breast milk after child attains ageof six months.After
the age of 6 months, breast milk is no longer sufficient to meet the nutritional requirements of infants.
However infants are vulnerable during the transition, from exclusive breast milk to the introduction of
complementary feeding, over and abovethe breastmilk. For ensuring that thee nutritional needsof a
young child are met breastfeeding must continue along with appropriate complementary feeding.The
term “complementary feeding” and not “weaning” should be used.The complementary feeding must be:
 Timely – meaningthat they are introduced when the need for energy and nutrients exceedswhat
canbe provided through exclusive breastfeeding.
 Adequate- meaningthey should provide sufficient energy, protein and micronutrients to meet the
growing baby’s nutritional requirement
 Safe-meaning they are hygienically prepared and stored and fed with clean handsusingclean
utensils and not bottles andteats.
Benefits of optimal Infant andYoungChildFeeding
 Reducesthe risk of childmortality
 Reducesthe risk of preventable infant and childhoodillnesses
 Enhancescognitive functions andincreasesproductivity
 Helps in spacingpregnanciesasbreastfeeding is the aneffective contraceptive (98.2%)during the
first sixmonths oflactation
 Reducesburden on health system andcosts for societies by protecting against malnutrition (both
under-nutrition andobesity) and infectious andchronicdiseases]
TechnicalGuidelines
Breastfeeding
WHO/UNICEFhave emphasizedthe first 1000daysof life i.e, the 270 daysin-utero andthe first two
years after birth asthe critical window period for nutritional interventions.As the maximal brain growth
occurs, malnutrition in this critical period canlead to stunting and suboptimal developmental outcome.
Theoptimal andappropriate infant and young child nutrition practices andstrategies areenumerated:
(a) Breastfeeding should be promoted to mothers and other caregivers asthegold standard feeding
option for babies.

52. (b)Antenatal Counsellingindividually or in groups organized by maternity facility should contain messages
regarding advantages of breastfeeding and dangers of artificial feeding. Theobjective should be to
prepare expectant mothers forsuccessfulbreastfeeding.
(c)Breastfeeding must be initiated asearly aspossible after birth for all normal newborns (including those
born by caesareansection) avoiding delay beyond an hour. In caseof operative birth, the mother may
need motivation andsupport to initiate breastfeeding within the first hour. Skinto skin contact between
the mother and newborn should be encouraged by ‘bedding in the mother and baby pair’. Themethod of
“Breast Crawl” canbe adopted for early initiation in caseof normal deliveries. Mother should
communicate, look into the eyes,touch andcaressthe babywhile feeding. Thenew born should be kept
warm by promoting KangarooMother Careandpromoting local practices to keepthe room warm.
(d)Colostrum, milk secreted in the first 2-3 days, must not be discarded but should be fed to newborn as
it contains high concentration of protective immunoglobulins and cells. No prelacteal fluid should be
given to the newborn. (e) Babyshould be fed “on cues”- Theearlyfeeding cuesincludes; sucking
movements andsucking sounds, hand to mouth movements, rapid eye movements, soft cooing or sighing
sounds,lip smacking, restlessness etc. Crying is alate cueandmay interfere with successfulfeeding.
Periodic feeding is practiced in certain situations like in the caseof avery small infant who is likely to
becomehypoglycemic unless fed regularly, or an infant who ‘does not demand’milk in initial few days.
Periodic feeding should be practiced only on medicaladvice.
(f)Every mother, especially the first time mother should receive breastfeeding support from the doctors
and the nursing staff, or community health workers (in caseof non-institutional birth) with regards to
correct positioning, latching and treatment of problems, suchasbreast engorgement, nipple fissures and
delayed ‘coming-in’ of milk.
(g)Exclusive breastfeeding should be practiced from birth till six months requirements. Human milk provides
sufficient energy and protein to meet nutritional requirements of the infant during the first 6 months of life.
Therefore,no other food or fluids should be given to the infant below six months of age unlessmedically indicated.
After completion of six months of age,with introduction of optimal complementary feeding, breastfeeding should
be continued for aminimum for 2 yearsand beyond depending on the choice of mother and the baby. Even during
the secondyear of life, the frequencyof breastfeeding should be 4-6 times in 24 hours,including night feeds.
(h)Mothers need skilled help and confidence building during all health contacts and also at home through
home visits by trained community worker, especiallyafter the babyis 3 to 4 months old when amother
maybegin to doubt her ability to fulfill the growing needsand demandsof the baby.
(i)Mothers who work outside should be assisted with obtaining adequate maternity/breastfeeding leave
from their employers; they should be encouragedto continue exclusive breastfeeding for 6 months by
expressingmilk for feeding the baby while they are out at work, andinitiating the infant on timely
complementary foods. Theymaybe encouragedto carry the baby to awork place crèchewherever such
facility exists. Theconcept of “Hirkani’s room” may be considered at work places (Hirkani’s room is a
specially allocated room at the workplace where working mothers canexpressmilk andstore in a
refrigerator during their work schedule). Everysuchmother leaving the maternity facility should be
taught manual expressionof her breastmilk.
(j)Mothers who are unwell or on medication should be encouragedto continue breastfeeding unless it is
medically indicated to discontinuebreastfeeding.
(k)At every health visit, the harms of artificial feeding andbottle feeding should be explained to the
mothers. Inadvertent advertising of infant milk substitute in health facility should be avoided.Artificial
feeding is to be practiced only when medicallyindicated.

53. (l) Frontline health workers should be trained in various skills of counselling and especially in handling
sensitive subjects like breastfeeding andcomplementaryfeeding.
m)If the breastfeeding is noted to be temporarily discontinued due to aninadvertent situation, “re-
lactation” should be tried assoonaspossible. Suchcasesshould be referred to atrained lactation
consultant/health worker. Thepossibility of “induced lactation” should be explored according tothe
needsof the specificcase.
(n)All efforts should betaken to provide appropriate facilities so that mothers can breastfeed babies
with easeeven in publicplaces.
(o) Adoption of latest WHOGrowth Chartsis recommended for growthmonitoring.
. ComplementaryFeeding
(a) Appropriately thick complementary foods of homogenous consistency made from locallyavailable
foods should be introduced at sixcompleted months to all babieswhile continuing breastfeeding
along with it. This should be the standard and universal practice. During this period breastfeeding
should be actively supported and therefore the term “weaning” should be avoided.
(b) Toaddress the issueof asmall stomach sizewhich canaccommodate limited quantity at atime,
eachmeal must be madeenergy denseby adding sugar/jaggery and ghee/butter/ oil. Toprovide
more calories from smaller volumes, food must be thick in consistency - thick enough to stay on
the spoon without running off, when the spoonis tilted.
(c)Foodscanbe enriched by making afermented porridge, useof germinated or sprouted flour and
toasting of grains beforegrinding.
(d) Adequate total energy intake canalsobe ensuredby addition of one to two nutritioussnacks
between the three main meals. Snacksare in addition to the meals and should not replace meals. They
should not to be confusedwith foodssuch assweets, chips or other processedfoods.
(e) Parents must identify the staple homemade food comprising of cereal-pulse mixture (asthese are fresh,
clean and cheap) and makethem calorie and nutrient rich with locally available products.
(f)Theresearch hastime and again proved the disadvantages ofbottle feeding. Hencebottle feeding should
be discouraged at alllevels.
(g) Population-specific dietary guidelines should be developed for complementary feeding basedon
the food composition of locally available foods.Alist of appropriate,acceptable and avoidable
foods canbe prepared.
(h) Iron-fortified foods, iodized salt, vitaminAenriched food etc. are to be encouraged.
(i) Thefood should be a“balanced food” consisting of various (asdiverse aspossible) food
groups/components in different combinations.Asthe babiesstart showing interest in
complementary feeds, the variety should be increased by adding new foods in the staple food one
by one. Easilyavailable, cost-effective seasonaluncooked fruits, green andother dark coloured
vegetables, milk andmilk products, pulses/legumes, animal foods, oil/butter, sugar/jaggery may
be addedin the staplesgradually.
(j) Junkfood and commercial food, ready-made, processedfood from the market, e.g. tinned
foods/juices, cold-drinks, chocolates, crisps, health drinks, bakery products etc. should beavoided
(k)Giving drinks with low nutritivevalue, suchastea, coffee andsugary drinks should also be
avoided.
(k) Consistency of foods should be appropriate to the developmental readinessof the childin
munching, chewing and swallowing. Foodswhich canpose choking hazardare to be avoided.
Introduction of lumpy or granular foods and most tastes should be done by about 9 to 10 months.
Missing this agemaylead to feeding fussinesslater. Souseof mixers/grinders to make food
semisolid/ pasty should be stronglydiscouraged.

54. During complimentary feeding this should beseen:
F- Frequency
A - Adequacy
T-Texture
V- Variety
A-Active Feeding
H- Hygiene
Age Texture Frequency Average amount eachmeal
6-8
months
Start with thickporridge,
wellmashedfoods.
2-3 mealsperdayplus
frequent BF.
Start with 2-3table
spoonfuls.
9-11
months
Finely choppedormashed
foods,and foodsthatbaby
can pickup.
3-4 mealsplusBF.
Dependingonappetiteoffer
1-2snacks.
½of a250mLcup/bowl.
12-23
months
Familyfoods,chopped
ormashedifnecessary.
3-4 mealsplusBF.
Dependingonappetite
offer1-2 snacks.
3/4 to one 250mLcup/bowl
HIV andInfant Feeding
Principles of feeding HIVexposedand infected infants are asfollows:
1.Exclusive breastfeeding is the recommended infant feeding choice in the first 6 months, irrespective
of whether mother or infant isprovided with ARVdrugs for the duration of breastfeeding.
2. Mixed feeding should not bepracticed.
3.Only in situations where breastfeeding cannot be done or on individual parents’informed decision,
replacement feeding may be considered only if all the criteria for replacement feeding are met.
4.Exclusive breastfeeding should be done for at least 6 months, after which complementary feeding
may be introduced gradually, irrespective of whether the infant is diagnosedHIV negative or positive by
early infant diagnosis.
5.Either mother or infant should be receivingARVprophylaxis or ARTduring the whole duration of
breastfeeding.ARVprophylaxis should continue for one week after the breastfeeding hasfullystopped.
6.For breastfeeding infants diagnosedHIVnegative, breastfeeding should be continueduntil 12 months
of age
7.For breastfeeding infants diagnosedHIVpositive, ARTshould be started and breastfeeding should be
continued till 2 years ofage.
8.Breastfeedingshouldstop once anutritionally adequate and safediet without breast-milk canbe
provided.

55. 9. Abrupt stopping of breastfeeding should NOTbe done. Mothers who decide tostop breastfeeding
should stop gradually over onemonth.
Feedingin preterm / low birth weightinfant
Feedingrecommendations for low birth weight infants :
1.All Low-birth-weight (LBW)infants, including those with very low birth weight (VLBW),should be fed
breast milk.
2.LBWinfants who are able to breastfeed should be put to the breast assoonaspossible after birth
(and when they are clinically stable). If unable to suckle, these babies should be fed with expressed
breast milk usingakatori andspoon.
3. LBWinfants should be exclusively breastfed until 6 months i.e 180 days ofage.
4.LBWinfants who cannot breastfeed and need to be fed by an alternative oral feeding method should
be fed by cup or spoon or asprescribed by thepaediatrician.
5.Very low birth weight infants should be given 10 ml/kg of enteral feedspreferably expressedbreast
milk, starting from 1st day of life with the remaining fluid requirement met by IV fluids.
6.LBWinfants, including those with VLBW,who cannot be fed mother’s own milk should be fed donor
(non HIVinfected) human milk. (This recommendation is relevant only to settings where safeand
affordable milk banking facilities are available or canbe set up suchasSNCU).

56. DAY-5
MALNUTRITION
Malnutrition is a pathological state resulting from a relative or absolute deficiency or excess of
one or more essential nutrients.
Malnutrition refers to deficiencies, excesses or imbalances in a person’s intake of energy and/or
nutrients. The term malnutrition covers 2 broad groups of conditions. One is ‘undernutrition’—
which includes stunting (low height for age), wasting (low weight for height), underweight (low
weight for age) and micronutrient deficiencies or insufficiencies (a lack of important vitamins
and minerals). The other is overweight, obesity and diet-related non-communicable diseases
(such as heart disease, stroke, diabetes and cancer).
It comprises of 4 forms:-
i)
ii)
iii)
Undernutrition: This is the condition which results when insufficient food is eaten
over an extended period of time. In extreme cases it is called starvation.
Overnutrition: This is the pathological state resulting from the consumption of
excessive quantity of food over an extended period of time. This can result in obesity
and metabolic syndrome.
Imbalance: This is a pathological state resulting from a disproportion among essential
nutrients with/without the absolute deficiency of a nutrient.
iv) Specific deficiency: It is a pathological state resulting from a relative or absolute lack of
an individual nutrient. Eg- Scurvy, Night blindness.
Causes of Malnutrition
Malnutrition is a man-made disease. It is a disease of human society. It begins quite
commonly in the womb and ends in the grave.
The great advantage of looking at malnutrition as a problem in human ecology is that it
allows for variety of approaches towards prevention. Jelliffe, 1966 listed the ecological
factors related to malnutrition. They are as follows:
i) Conditioning influences: Infectious diseases are important conditioning factor
responsible for malnutrition particularly in small children. Diarrhoea, intestinal
parasite, measles, whooping cough, malaria, tuberculosis, etc contribute to
malnutrition.
Infact it is vicious cycle, infection contributing to malnutrition and malnutrition
causing otherwise minor childhood ailments to be killers. It has been seen that where
environmental conditions are poor small children may suffer from some infections or

57. the other for almost half of their first 3 years of life. The inter- relationship between
malnutrition and infection has been established.
ii) Cultural influences: Lack of food is not the only cause for malnutrition. Too often
there is starvation in the middle of plenty. People choose poor diets when good ones
are available because of cultural influences which vary widely from country and from
region to region. They may be stated as follows:
 Food habits, customs, beliefs, traditions and attitudes : Food habits are among
the oldest and most deeply rooted of any culture. They have deep
psychological roots and are associated with love, affection, warmth and social
prestige. The family plays an important role in shaping the food habits and
these habits are passed from one generation to another.
 Traditional beliefs like papaya should be avoided during pregnancy as it cause
abortion and concepts of certain foods being harmful to child and even beliefs
about hot and cold food, light and heavy foods and unhealthy food choices
which ultimately leads to malnutrition.
 Religion: Religion has a powerful influence on the food habits on the people.
Hindus do not eat beef and Muslims do not eat pork. Some orthodox Hindus
and Jains avoid certain vegetables like onions, garlic, etc. These are known as
food taboos which prevent people from consuming nutritious food even when
they are easily available.
 these are called food fads. Food fads may stand in the way of correcting
nutritional deficiency.
 Cooking practices: Draining away the rice water at the end of cooling,
prolonged boiling in open fans, peeling of vegetables, chopping vegetables into
smaller pieces, etc influences the nutritional status of the individuals.
 Child rearing practices: It vary widely from region to region and influences the
nutritional status of infants and children. Eg- premature curtailment of breast
feeding, adoption of bottle feeding and commercially produced refined foods,
etc.
 Miscellaneous factors: In some communities men eat first and women eat last
and poorly. Consequently that health of women in these societies may be
adversely affected. Chronic alcoholism is another factor that leads to serious
malnutrition.
iii) Socio-economic factors: Malnutrition is largely is a by-product of poverty,
ignorance, insufficient education, lack of knowledge, regarding the nutritive value of
foods, unhygienic sanitary environment, large family size, etc. These factors are

58. directly related to the quality of life and are the true determinants of malnutrition in
society.
ACUTE MALNUTRITION
Acute malnutrition is a devastating epidemic. Worldwide, some 55 million children under the
age of five suffer from acute malnutrition, 19 million of these suffer from the most serious type –
severe acute malnutrition. Every year, 3.1 million children die of malnutrition.
The human body needs energy and nutrients to function. If food intake is inadequate, the body
begins to break down body fat and muscle, the metabolism begins to slow down, thermal
regulation is disrupted, the immune system is weakened, and kidney function is impaired.
Decreased food consumption, increased energy expenditure, and illness result in a poor
nutritional state known as malnutrition (or undernutrition). Malnutrition is associated with
increased illness and death, reduced educational achievements, productivity and economic
capacity. Poverty, inequality, and malnutrition are often passed from one generation to the
next.
Malnutrition manifests itself in the form of micronutrient deficiencies, stunting (also known as
chronic malnutrition), and/or acute malnutrition.
Acute malnutrition is a form of under-nutrition caused by a decrease in food consumption and/or
illness that results in sudden weight loss or oedema (fluid retention). Acute malnutrition can be
moderate or severe, and prolonged malnutrition can cause stunted growth, otherwise known as
stunting. Stunting in early childhood has health consequences that can affect children throughout
their entire lives. Action Against Hunger treats acute malnutrition with a combination of
community-based management and therapeutic foods/Ready-to-use therapeutic foods (RUTFs).

59. TYPES OFACUTEMALNUTRITION
MODERATEACUTEMALNUTRITION
Moderate acute malnutrition (MAM), also known as wasting, is defined by a weight-for-height
indicator between -3 and -2 z-scores (standard deviations) of the international standard or by a
mid-upper arm circumference (MUAC) between 11 cm and 12.5 cm
.
SEVEREACUTEMALNUTRITION
Severe acute malnutrition (SAM) is another types of acute malnutrition and one the most
dangerous forms. If left untreated, SAM can result in death. It can manifest in two ways:
1. SEVEREWASTING
Another type of acute malnutrition is severe wasting. This is characterized by a massive loss
of body fat and muscle tissue. Children who are severely wasted look almost elderly and their
bodies are extremely thin and skeletal.
2. OEDEMA
In this form of severe acute malnutrition, oedema is present on the lower limbs, and is
verified when thumb pressure is applied on top of both feet for three seconds and leaves a pit
or indentation in the foot, after the thumb is lifted. The oedema may eventually spread to the
legs and face, and the child appears puffy, and is usually irritable, weak, and lethargic. Other
signs of oedema include skin lesions, an enlarged liver and thinning hair. Underneath the
oedema, the muscles have been severely weakened and the child experiences excruciating
cramping and muscle pain. A severely malnourished child with oedema is at high risk of
death and requires immediate treatment.

60. Bilateral Peeting Oedema
Both types of severe acute malnutrition compromise the body’s vital processes. Even if a
malnourished child is treated and his/her nutritional status is restored, his/her physical and
mental development and general health status may be adversely effected in the long term.
Both moderate acute malnutrition and severe acute malnutrition may be accompanied by
micronutrient deficiencies such as iron deficiency or nutritional anemia, iodine deficiency
disorders and vitamin A deficiency.
Globally, moderate acute malnutrition affects a greater number of children than severe
acute malnutrition. While children suffering from either moderate acute malnutrition or severe
acute malnutrition are susceptible to illness, severely malnourished children are at greater risk of
medical complications and death from illness, infections, and micronutrient deficiencies.

61. Mother and Child Protection Card (MCPC)
The Mother and Child Protection Card (MCP Card) has been introduced through a collaborative
effort of the Ministry of Women and Child Development and the Ministry of Health & Family
Welfare, Government of India.
The MCP card is a tool for informing and educating the mother and family on different aspects
of maternal and child care and linking maternal and childcare into a continuum of care through
the Integrated Child Development Services (ICDS) scheme of Ministry of Women and Child
Development and the National Rural Health Mission (NRHM) of the Ministry of Health &
Family Welfare (MoHFW).
The card also captures some of key services delivered to the mother & baby during Antenatal,
Intranatal & Post natal care for ensuring that the minimum package of services are delivered to
the beneficiary.
MCP card has already been disseminated in the year 2010-11 for implementation by the States.
The MCP card helps in timely identification, referral and management of complications during
pregnancy, child birth and post natal period. The card also serves as a tool for providing
complete immunization to infants and children, early and exclusive breast feeding,
complementary feeding and monitoring their growth.

62. Mother and Child Protection Card
Who uses the card ?
The card could be used by the following individuals and groups.
A . Family members (Mothers, Fathers, Mother-in-laws, Adolescent girls and others)
1. For gaining knowledge related to children’s health, nutrition and development.
2. For using all available services.
3. For practicing optimal care behaviors.
4. For monitoring and promoting growth and development of children.
B . Village groups/Women (Mahila Mandal) groups
1. As a discussion tool in the meetings.
2. Monitoring effective service delivery in the area.
C . ANM / AWW
1. For educating families about optimal health, nutrition and care practices.
2. For recording information on utilization of services.
3. For appropriate referrals.
D . Health and ICDS Supervisors
For ensuring that:
1. the card is introduced to targeted families
2. its use is properly explained to the families with support materials; and
3. there is effective and efficient delivery of services to the target families.
Who keeps the card?

63. 1. Pregnant women
2. Mothers of children under 3 years of age
GROWTH MONITORING
What is Growth Monitoring?
Weighing of the child at regular intervals, the plotting of that weight on a graph (called growth
chart) enabling one to see changes in weight and rendering counselling to the mother/care-giver.
 Monitoring means keeping a regular track of something, like every week or every month
 Weighing of the child at regular intervals, the plotting of that weight on a graph (called a
growth chart) enabling one to see changes in weight, and giving advice to the mother
based on this weight change is called ‘GROWTH MONITORING’
 It is the change in weight over a period of time which is most important, rather than the
weight itself.
 Should be done once every month, up to age of 3 years and at least once in 3 months,
thereafter.
Methods of Growth Monitoring
 Weight for Age :
 Single best parameter for assessing physical growth.
 Careful repeated measurement at intervals, ideally from birth- 1 month weekly, one
month- 3 years every month and 3-5 years at every three months is very important.
 Compare these measurements with reference standards of weight of children of the same
age.
 Best done on growth chart.
 Height for Age :
 Height should be taken in a standing position without footwear with the help of height
machine or measuring scale fixed to the wall.
 Suitable for children 2 years or above.
 The length of the baby at birth is about 50 cm. It increases by about 25 cm during first
year and by another 12 cm during the second year.
 Height is a stable measurement of growth as opposed to body weight. Whereas weight
reflects only the present health status of the child, height indicates the events in the past
also.

64.  Low height for age: also known as nutritional stunting or dwarfing. Reflects past or
chronic malnutrition.
 Weight for Height:
 Weight and Height are interrelated.
 If there is low weight for height, it is called as nutritional wasting or emaciation (acute
malnutrition).
 A child less than 70 percent of the expected weight for height is classed as severely
wasted.
 Head and Chest circumference:
 At birth head circumference is about 34 cm, about 2 cm more than the chest
circumference.
 By the age of 6 to 9 months, these two measurements become equal, after which the chest
circumference overtakes.
 This overtaking maybe delayed by 3 to 4 years in severely malnourished children.
 According to an ICMR study conducted in 1984, the crossing over of chest and head
circumference did not take place until the age of two years and six months in poor Indian
children.
STEPS IN GROWTH MONITORING
 Five steps:-
 Step 1: Determining correct age of the child.
 Step 2: Accurate weighing of the child.
 Step 3: Plotting the weight accurately on a growth chart of appropriate gender.
 Step 4: Interpreting the direction of the growth curve and recognizing if the child is
growing properly.
 Step 5: Discussing the child’s nutritional status with the mother or other care-givers,
counseling and follow ups.
Weighing of Infants and Children
 The two types of scales are being used ICDS for weighing children
1. The ‘bar scale’ and
2. The ‘salter or dial type scale’

65. Salter weighing scale
New ICDS Growth Chart
 Also known as “Road to Health” Charts
 Is a part of the Mother Child Protection (MCP) Card
 Contains weight-for-age growth charts based on New WHO Child Growth Standards
 Separate growth charts for girls and boys.
 The first half of the register has growth charts for girls with ‘pink border’ and the second
half is for boys with the ‘blue border’

66. Growth Chart for Boys
Growth Chart for Girls

67. DAY6
Anthropometric Measurements
Anthropometric measurements are a series of quantitative measurements of the muscle, bone,
and adipose tissue used to assess the composition of the body. The core elements of
anthropometry are height, weight, body mass index (BMI), body circumferences (waist, hip, and
limbs), and skin fold thickness.
Anthropometric measurements commonly used for children include height, weight, mid-upper
arm circumference (MUAC), and head circumference. Bilateral pitting edema, a clinical
indicator, is often assessed along with anthropometry. Some measurements are presented as
indices, including length/height-for-age (HFA), weight-for-length/height (WFH), weight-for-age
(WFA), body mass index-for-age (BMI-for-age), and head circumference-for-age. Each index is
recorded as a z-score, which describes how far and in what direction an individual’s
measurement is from the median of the World Health Organization Child Growth Standards. A z-
score that falls outside of the “normal” range indicates a nutritional issue. MUAC and low birth
weight measurements are compared to cutoffs that apply to all children in a specific age range.
 MUAC (Tape)
 HEIGHT (Stadiometer / Infantometer)
 WEIGHT (weighing scale / for less than 2 months old spring balance)
 HEAD and CHEST Circumference
BASICS OF COUNSELLING
 Being a Good Counsellor
 Empathic
 Open- minded
 Confidential
 No body contact with the client
 No consoling the client
 Let them cry
 No sympathy
 Be Tactful
 Be Prudent
 Not being emotional
 Cannot be judgemental
 Have patience
 Should have simple words

68.  Should unlearn
 Needs communication skills
 Needs team building