This document outlines the RMNCH+A framework in India, which aims to improve reproductive, maternal, newborn, child and adolescent health through an integrated approach. It discusses the problem statement, goals and targets, strategic interventions across the lifecycle from adolescence to reproductive years. These include adolescent health services, antenatal care, skilled birth attendance, essential newborn care, immunization, and family planning. The framework also covers health system strengthening, program management, priority actions in vulnerable areas, and partnerships to support RMNCH+A service delivery in India.

1. RMNCH + A
Dr. Krithiga S
Post Graduate
Community Medicine

2. FRAMEWORK
 INTRODUCTION AND RATIONALE
 PROBLEM STATEMENT
 CAUSES OF MATERNAL AND CHILD
DEATHS
 GOALS AND TARGETS
 STARTEGIC RMNCH+A
INTERVENTIONS
 HEALTH SYSTEM STRENGTHENING
 PROGRAMME MANAGEMENT
 PRIORITY ACTIONS
 PARTNERSHIP AND SUPPORT

3. INTRODUCTION AND RATIONALE
• Improving the maternal and child health --NRHM & MDG .
• To bring greater impact - recognise that reproductive, maternal and child health
cannot be addressed in isolation
• Different stages of life cycle and levels of provision of health care are
interlinked

4. • The two dimensions of health care a) stages of life cycle b )places where the
care is provided.
RMNCH + A
• (1) inclusion of adolescence as a distinct ‘life stage’
• (2) linking of maternal and child health to reproductive health and other
components (like family planning, adolescent health, HIV, etc)
• (3) linking of community and facility-based care as well as referrals
between various levels of health care system
• This integrated strategy promotes greater efficiencies & reduces
duplication of resources and efforts in the ongoing programme.

5. PROBLEM STATEMENT
STATISTICS OF 2010
Global maternal deaths (2010)
Maternal Mortality Ratio
2,87,000
210/100,000
Indian maternal deaths 56000
CHILD MORTALITY(global) 76 LAKHS
CHILD MORTALITY(India)
under five mortality
15.8 LAKH 20% OF TOTAL
59 /1,000 live births
56% 1st month
79% in1st yr
TFR IN INDIA 2.5

6. •RURAL – URBAN DIFFERENCE IN MMR IS
~ 28 / 100,000
•RATE OF DECLINE OF RURAL MMR
greater
•FOCUS SHOULD BE SHIFTED to areas of
greatest concern & populations that carry the
highest burden of illness
PROGRESS IN INDIA OLDER STATS PRESENT
STATS
CHILD MORTALITY RATE 115 /1000 IN
1990
56 /1000
MATERNAL MORTALITY
RATE
254/ 100’000 IN
2005
214/100’000
IN 2007-09

7. Causes of Under-Five Deaths

8. Causes of maternal deaths
SOCIAL CAUSES
1. Marriage and child
birth at young age
2. Less spacing
between births
3. Low literacy level
among women
4. Reduced Access to
use of contraception
/ safe abortion
methods

9. HEALTH SYSTEM RELATED CAUSES
Lack of awareness Delay in decision to
seek care
Unavailability of
basic health services
Delay in reaching
appropriate facility
Poor quality of
care
Delay in receiving
quality care

11. BOTTLENECK ANALYSIS
1. Availability of essential
commodity
2. Access to services
3. Utilization of services
4. Adequate coverage
5. Effective coverage
• Limited availability of skilled
human resource
• Low coverage of service
• Inadequate supervision
• Low quality of training
• Lack of improvement of quality
of services
• Inadequate IEC

12. GOALS
Health Goals- 12th Five Year Plan
• IMR 25 / 1000 live births
• MMR 100 per 100,000 live births 2017
• TFR 2.1
The country aims to set one collective goal towards reducing
preventable maternal, newborn and child deaths by 2017

13. Coverage targets RMNCH+A 2017
Facilities equipped for perinatal care 100
Proportion of all births in government and
accredited private institutions
Annual rate of 5.6%
Proportion of pregnant women receiving
antenatal care at annual rate of 6%
Annual rate of 6%
Proportion of mothers and newborns
receiving postnatal care
Annual rate of 7.5%
Proportion of deliveries conducted by skilled
birth attendants at annual rate of 2% from
the baseline
Annual rate of 2%

14. Exclusive breast feeding rates annual rate of 9.6%
Reduce prevalence of under-five children who are
underweight
annual rate of 5.5%
Increase coverage of three doses of combined
diphtheria-tetanus-pertussis
Annual rate of 3.5%
Increase ORS use in under-five children with
diarrhoea
at annual rate of 7.2 %
Reduce unmet need for family planning methods annual rate of 8.8%
Increase met need for modern family planning methods
among eligible couples
at annual rate of 4.5%
Reduce anaemia in adolescent girls and boys (15–19 yrs) annual rate of 6%
Decrease the proportion of total fertility contributed by
adolescents
annual rate of 3.8%

16. STRATEGIC INTERVENTIONS
 Care for ADOLESCENTS
 Care for PREGNANT WOMEN AND NEWBORN
 ESSENTIAL NEWBORN CARE AND RESUSCITATION
 Measures through reproductive years

17. ADOLESCENCE
Adolescent health has inter-generational effect.
PROBLEMS IN ADOLESCENT AGE GROUP
• Nutritional defects
• Sexual and reproductive health related problems
• Mental health based problems
• Gender based violence
• Substance use / non communicable disease
1/3 rd of married adolescents face domestic

18. ADOLESCENT NUTRITIONAL
SUPPORT
nutrition – growth and sexual
maturation
WEEKLY IFA
SUPPLEMENTATION
PROGRAM
Supervised administration of
weekly Fe (100mg) and F.A (500
mcg)in schools
Screening for anemia
and referral to health
facility
Bi annual deworming
Counseling to improve
dietary intake / prevent worm
infestations
Non school going adolescents – covered by anganwadi centre

19. SUB CENTRE
LEVEL
ANM
PRIMARY HEALTH
CENTRE
Adolescent information and
counseling centre
( M.O AND ANM)
ALL HIGHER
CENTRES
Adolescent health clinics
Adolescent counselors
SPECIALACTIVITIES
•Linkage with ICTC/ appropriate referrals for RTI s and STDs
Adolescent friendly health services

20. INFORMATION AND
COUNSELLING
LIFE SKILL EDUCATION- schools /
anganwadi centres / outreach Programmes
•Promote healthy lifestyle
•addictions and substance abuse
•to reduce gender based violence
•Risk of early conception
PEER EDUCATION APPROACH :Peer
educators to counsel the adolescents
regarding mental health issues
• screening &Appropriate referrals
OTHER INVERVENTIONS

21. MENSTURAL HYGIENE •Information and knowledge about
use of sanitary napkins,
• quality products made available
PREVENTIVE HEALTH
CHECK UPS
•Biannual health screening
•Basic health services and referrals
•Immunization
•Micronutrient supplementation
•Deworming

22. PREGNANCY AND CHILDBIRTH
1. Delivery of antenatal care package and tracking of high-risk
pregnancies
2. Skilled obstetric care
3. Immediate essential newborn care and resuscitation
4. Emergency obstetric and new born care
5. Postpartum care for mother and newborn
6. Postpartum IUCD and sterilisation
7. Implementation of PC&PNDT Act

23. Newborn and Childcare
• Home-based newborn care and prompt referral
• Facility-based care of the sick newborn
• Child nutrition and essential micronutrients supplementation
• Immunisation
• Integrated management of common childhood illnesses (diarrhoea,
pneumonia and malaria)
• Early detection and management of defects at birth, deficiencies,
diseases and disability in children (0–18 years)

24. Home based newborn care and
prompt referral
• Neonatal deaths - 59% of under-five mortality at the national level
• Reducing neonatal mortality is paramount imporatance to impact IMR
• The home-based newborn care scheme,(2011,) provides for immediate postnatal
care (especially in the cases of home delivery) and essential newborn care to all
newborns up to the age of 42 days.
• ASHA are trained and incentivised to provide special care to preterms and
newborns & identification of illnesses, appropriate care and referral through
home visits.

25. Facility-based care of the sick
newborns
• Special Newborn Care Units - established at District Hospitals and tertiary
care hospitals
• The goal - SNCU in each district of the country. Additionally, health facilities
> 3,000 deliveries /yr can be considered for establishing an SNCU
• Another smaller unit known as the Newborn Stabilisation Unit which is a four-
bedded unit providing basic level of sick newborn care, is being established at
Community Health Centres/First Referral Units.
• Sick newborns - followed up for Developmental Screening and Early
Intervention

26. Child nutrition and essential micronutrients
supplementation
• Line listing LBW babies maintained and follow up should be ensured
• All children between the ages of 6 months to 5 years – IFA tablets or
syrup (IFA) (for 100 days / year )
• Vitamin A supplementation ( 9 months to 5 years - six monthly
doses of vitamin A. nine doses of Vitamin A by the 5th birthday)
• Reduce the risk of mortality due severe acute malnutrition,
Nutritional Rehabilitation Centres have been established for
providing medical and nutritional care.

27. Immunisation
• India - 2.6 crore/yr.
• UIP - prevent seven vaccine preventable
diseases
New inclusions :
• The 2nd dose of measles ,Hep B vaccine JE
(endemic districts)
• Pentavalent vaccine
• Adverse effects investigation report - within
15 days

28. Through the Reproductive Years
• Community-based promotion and delivery of
contraceptives
• Promotion of spacing methods (interval IUCD)
• Sterilisation services (vasectomies and tubectomies)
• Comprehensive abortion care (includes MTP Act)
• Prevention and management of sexually transmitted
and reproductive infections (STI/RTI)

29. Health Systems Strengthening
for RMNCH+A Services
•Infrastructure •New construction and renovation of existing
facilities
•Delivery points
•Maternal and Child Health (MCH) Wing
•Human resources
•Policies on drugs, diagnostics, equipment ,procurement system and
Logistics management
• Providing and Improving Quality of care

30. Delivary point :
These are be strengthened for providing comprehensive services
• Referral transport system that reaches the patient within 30 minutes of
receiving a call and the health facility within the next 30 minutes.
• The long-term goal - establish a Basic Emergency Obstetric Care &
Comprehensive Emergency Obstetric Care centres,
No of deliveries/month type
min 3 normal deliveries L1
min 10 deliveries &
management of Complications
L2
min 20-50 including
C-section
L3

31. Maternal and Child Health (MCH) Wing:
• MCH wings will be comprehensive units (30/50/100 bedded)
with antenatal waiting rooms, labour wing, Essential Newborn
Care room, SNCU, operation theatres, blood storage units and
a postnatal ward as well as an academic wing.
• ensure provision of emergency maternal and newborn care
services as well as 48 hrs stay & quality postnatal care to
mothers and newborns.

32. Programme Management
•Deputy Commissioners,
•Assistant Commissioners,&team of
technical consultants
•Director for RCH
•separate directorate officials for -facility
operationalization, training and quality assurance
systems.
•Directorate official (possibly Additional Chief Medical and
Health Officer /RCH Officer) for RMCNH+A,
•supported by separate dedicated full-time staff for each
components
DISTRICT
LEVEL
STATE LEVEL
NATIONAL
LEVEL

33. Community participation
• it is a key strategy NRHM
• to ensure that services reach those for whom they were meant.
• Engage women systematically at the community level
• Engage Village Health Sanitation and Nutrition committees
• Utilize the Village Health and Nutrition Days as a platform for outreach
activity
• Social audit and communitisation efforts at the Panchayati Raj level

34. Priority Actions in High Focus Districts and
Vulnerable Population (Urban Disadvantaged and
Tribals)
• Reaching the Unreached- in under served areas the topmost
priority.
• Differential planning and need-based financing
• Strengthening health infrastructure
• Incentives for personnel in hard-to-reach areas
• Public private partnerships
• Mobile Medical Units (MMU) and Maternity waiting homes

35. Tribal Health
• The states - map out tribal areas and pockets
• closely monitor progress on all health activities in notified tribal areas.
Strategies for inaccessible/remote hilly areas
• Transport
• Incentives
• Birth waiting homes
Health of the urban poor
• UHC close to slums and urban community health centres(30-50 bedded )
with lab services
• USHA – preventive and promotive actions

36. Convergence and Partnerships
Convergence with on-going programmes
• National Vector Borne Disease Control Programme (NVBDCP):
• National AIDS Control Programme:
• AYUSH
• National Urban Health Mission (NUHM)
• PC&PNDT Act implementation
• Adolescent health, maternal and child health programmes
Partnerships
• The professional bodies like IAP IAPSM FOGSI key role in advancing
knowledge,practice of evidence-based interventions & assist the
government

37. Technical Support for RMNCH+A Service Delivery
Ministry of Health and Family Welfare
(MOHFW):
Monitoring, management and coordination
National Child Health Resource Centre Acts as repository of all technical and
programme guidelines
Regional Collaborative Centres for
reproductive, maternal, newborn child and
adolescent health
To support the states in capacity building,
research and programme monitoring
RMNCHA Coalition will proactively engage with the RMNCH
efforts of the Global Strategy for Women and
Children’s Health and the Independent
Review Group
India Call to Action on child survival and
development
Technical support at national and priority
states and districts