maternal and child health in national programs

1. Provisions for Maternal and
Child health under National
Health Mission.
RAVI M R
POST GRADUATE STUDENT

2. 1st may
2013
Monday,
September 15,
2014

3. Vision of the NHM
“Attainment of Universal Access to Equitable, Affordable and Quality health
care services, accountable and responsive to people’s needs, with effective
inter- sectoral convergent action to address the wider social determinants of
health”
Monday,
September 15,
2014
National Health Mission

4. Sources for framework of NHM
1. It builds on the Framework for Implementation approved by the Cabinet
in 2006, for the first phase of the NRHM
2. Learning from NRHM implementation over the past seven years,
documented in several evaluation reports and studies and the experiences
of people and practitioners across the rural areas of the country
3. Chapter on Health of the Twelfth Plan provides the broad guidance for
this Framework
Monday,
September 15,
2014

5. Core Values
• Safeguard the health of the poor, vulnerable and disadvantaged,
and move towards a right based approach to health through
entitlements and service guarantees
• Strengthen public health systems as a basis for universal access
and social protection against the rising costs of health care.
• Build environment of trust between people and providers of
health services
Monday,
September 15,
2014

6. • Empower community to become active participants in the process of
attainment of highest possible levels of health.
• Institutionalize transparency and accountability in all processes and
mechanisms.
• Improve efficiency to optimize use of available resources
Monday,
September 15,
2014

7. Goals of National Health Mission
1) Reduce MMR to 1/1000 live births
2) Reduce IMR to 25/1000 live births
3) Reduce TFR to 2.1
4) Prevention and reduction of anaemia in women aged 15–49 years
5) Prevent and reduce mortality & morbidity from communicable,
noncommunicable diseases; injuries and emerging diseases
Monday,
September 15,
2014

8. 6) Reduce household out-of-pocket expenditure on total health care
expenditure
7) Reduce annual incidence and mortality from Tuberculosis by half
8) Reduce prevalence of Leprosy to <1/10000 population and incidence
to zero in all districts
9) Annual Malaria Incidence to be <1/1000
10) Less than 1 per cent microfilaria prevalence in all districts
11) Kala-azar Elimination by 2015, <1 case per 10000 population in all
blocks
Monday,
September 15,
2014

9. Provision for Maternal and child
health under National Health
Mission
Monday,
September 15,
2014

10. • All schemes and programmes that constituted RCH-II would be absorbed
into the NHM.
• NHM provides an opportunity to build on past work and renew the
emphasis on strategies for improving maternal and child health through a
continuum of care and the life cycle approach.
• The inextricable linkages between adolescent health, family planning,
maternal health and child survival have been recognized
Monday,
September 15,
2014

11. • Another dimension of the continuum of care which will receive attention is
the linking of community and facility-based care and strengthening
referrals between various levels of health care system to create a
continuous care pathway.
• All these aspects are embodied in the ‘Strategic Approach to Reproductive,
Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India’.
Monday,
September 15,
2014

12. Maternal Health
• Essential Obstetric Care
– Improved access to essential obstretic care through facility development.This includes
quality antenatal care including prevention and treatment of anemia, institutional / safe
delivery services and post natal care
• Quality Ante Natal care
– Quality ANC includes minimum of at least 4 ANCs including early registration
– 1st ANC in first trimester along with physical and abdominal examinations, Hb
estimation and urine investigation , 2 doses of T.T Immunization
– consumption of IFA tablets for 100 days.
Monday,
September 15,
2014

13. • Post natal care for mother and newborn
– Ensuring post natal care within first 24 hours of delivery
– Subsequent home visits on 3rd, 7th,and 42nd day is the important components for
identification and management of emergencies occurring during post natal period.
– The ANMs, LHVs and staff nurses are being oriented and trained for tackling
emergencies identified during these visits.
Monday,
September 15,
2014

14. • Skilled Attendance at Birth
– commitment to provide skilled attendance at every birth both at community and
Institution level.
– To manage and handle some common obstetric emergencies at the time of birth, a
policy decision has been taken permitting Staff Nurses (SNs) and ANMs to give
certain injections and also perform certain interventions under specific emergency
situations to save the life of the mother.
– They are permitted to use following drugs
– Inj Oxytocin, Inj Magnesium sulphate, Inj Gentamicin
– Oral – Metronidazole, Misoprostol, Ampicillin
– Also permitted to start an IV Infusion in emergency
Monday,
September 15,
2014

15. • Provision of Emergency Obstetric and Neonatal Care at FRUs
– Provision of Emergency Obstetric and Neonatal Care at FRUs is being done by
operationalziing all FRUs in the country.
– While operationalising, the thrust is on the critical components such as manpower,
blood storage units and referral linkages etc.
– Availability of trained manpower (Skill Based Training for MBBS doctors) is linked
with operationalization of FRUs
Monday,
September 15,
2014

16. • Augmentation of skilled human resources for Maternal Health:
– to overcome the shortage of skilled manpower particularly Anesthetists and
Gynecologists, the following key skill based training programs are being
implemented:
• An 18 Weeks Training Progamme of MBBS Doctors in Life Saving Anesthesia Skills for
Emergency Obstetric Care.
• A 16 weeks Training programme of MBBS Doctors in Obstetric Management Skills
including C-Section, in collaboration with Federation of Obstetric and Gynecological
Society of India.(CEmOC).
• A 10 days Training Programme in Basic Emergency Obstetric Care for Medical
Officers(BEmOC)
• A 3 weeks Training Programme for ANMs/SNs/LHVs as Skilled Birth Attendants(SBA)
Monday,
September 15,
2014

17. • Referral Services at both Community and Institutional level
– establish a network of Basic patient care transportation ambulances with aim to reach
the beneficiary in rural area within 30 minutes of the call for quick service delivery.
– Presently states have been given the flexibility to establish assured referral systems to
transport pregnant mothers and sick newborns, etc which includes different models
including public, private partnership models
Monday,
September 15,
2014

18. • Safe Abortion Services/ Medical termination of Pregnancy (MTP):
– Provision of comprehensive safe abortion services at public health facilities
including 24*7 PHCs/ FRUs (DHs/ SDHs /CHCs) with a focus on "Delivery Points“
– Capacity Building of Medical officers in safe MTP Techniques and of ANMs,
ASHAs and other field functionaries to provide confidential counseling for MTP and
promote post-abortion care including adoption of contraception.
– District Level Committees have been framed and empowered to accreditate the
facilities for conducting safe abortion services under MTP Act including approval of
private and NGO sector facilities for conducting MTPs.
Monday,
September 15,
2014

19. – Supply of Nischay Pregnancy detection kits to sub centres for early detection of
pregnancy so that safe abortion services can be provided to intended pregnancies
covered under the MTP Act.
– Development of standard IEC/BCC material on Safe Abortion.
– Orientation/Training of ASHAs to equip them with skills to create awareness on
abortion issues in women and the community and facilitate women in accessing
services.
Monday,
September 15,
2014

20. • Provision of RTI/STI services:
– provision of STI/RTI care services is a very important strategy to prevent HIV
transmission and promote sexual and reproductive health under the National
AIDS Control Program (NACP III) and Reproductive and Child Health (RCH
II)
– Enhanced Syndromic case management (ESCM) with minimal laboratory tests is
the cornerstone of STI/RTI management under NACP III
– Services are being provided to all FRUs, CHCs and at 24 X 7 PHCs.
– Special focus would be given on linking up with Integrated Counselling and Treatment
Centres (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI
management
Monday,
September 15,
2014

21. • Setting up of Blood Storage Centers (BSC) at FRUs:
– Timely treatment of complications associated with pregnancy is sometimes hampered
due to non-availability of Blood Transfusion services at FRUs.
– The Drugs and Cosmetics Act has been amended to facilitate establishment of
Blood Storage Centers at such FRUs.
Monday,
September 15,
2014

22. • Janani suraksha yojana and Janani Shishu Suraksha Karyakaram (JSSK):
– The Janani Suraksha Yojana (JSY) which enables institutional delivery will be
modified in the NHM period to synergize with the new Food Security legislation.
– Another key goal is to move towards UHC through an expanding comprehensive
package of free and cashless services currently covering all pregnant women, and sick
infants up to the age of one year, in government health institutions through Janani
Shishu Suraksha Karyakram (JSSK), thereby reducing financial barriers to care and
improving access to health services by eliminating OOP expenditure in all government
facilities
Monday,
September 15,
2014

23. • Maternal Death Review:
– The process of maternal death review (MDR) has been implemented &
institutionalized by all the States as a policy since 2010.
– Guidelines and tools for conducting community based MDR and Facility based MDR
have been provided to the States.
– The States are reporting deaths along with its analysis for causes of death.
Monday,
September 15,
2014

24. • Delivery Points (DPs):
– All the States & Union Territories have identified DPs above a certain minimum
benchmark of performance.
– To prioritize and direct resources in a focused manner to these facilities for filling the
gaps like trained and
– skilled human resources, infrastructure, equipments , drugs and supplies, referral
transport etc. for providing
– quality & comprehensive RMNCH (Reproductive, Maternal, Neonatal & Child
Health) services.
Monday,
September 15,
2014

25. • Web Enabled Mother and Child Tracking System:
– Name Based Tracking of Pregnant Women and Children has been initiated by
Government of India as a policy decision to track every pregnant woman , infant &
child upto 3 yrs, by name for provision of timely
– ANC, Institutional Delivery, and PNC along-with immunization & other related
services.
Monday,
September 15,
2014

26. • A Joint MCP
Card:
– Ministry of
Health &
Family Welfare
and Ministry of
Women and
Child
Development
(MOWCD) has
been launched
as a tool for
documenting
and monitoring
services for
antenatal,
intranatal and
postnatal care to
pregnant
women,
immunization
and growth
monitoring of
infants.
Monday,
September 15,
2014

27. • Tracking of severe Anaemia during pregnancy & child birth by SCs and
PHCs:
– severe anemia is a major cause for pregnancy related complications that may lead
to maternal deaths.
– Effective monitoring of these cases by the ANM as well as the Medical Officer in
charge of PHC has been started to line list these cases and provide necessary
treatment.
• Technical Guidelines & Service Delivery Posters:
– GoI has developed & disseminated standard technical guidelines & service delivery
posters for standardizing
– the quality of service delivery during ANC, INC, PNC, etc from tertiary to primary
level of institutions.
Monday,
September 15,
2014

28. • Gender Based Violence:
– The steps towards enabling a system wide response to gender based violence (GBV)
include: sensitize and train frontline workers and clinical service providers to identify
and manage GBV, train ASHAs to identify and refer/counsel cases of GBV in the
community,
– develop effective referral mechanisms from primary care to secondary and tertiary
centres, with assured services, build functional referral linkages and create follow up
mechanisms with government departments and NGOs providing legal and social
welfare services and women’s support groups in the district.
Monday,
September 15,
2014

29. New Born and Child Health
• Thrust Area 1 : Neonatal Health
– Essential new born care (at every ‘delivery’ point at time of birth)
– Facility based sick newborn care (at FRUs & District Hospitals)
– Home Based Newborn Care
• Thrust Area 2 : Nutrition
– Promotion of optimal Infant and Young Child Feeding Practices
– Micronutrient supplementation (Vitamin A, Iron Folic Acid)
– Management of children with severe acute malnutrition
Monday,
September 15,
2014

30. • Thrust Area 3: Management of Common Child hood illnesses
– Management of Childhood Diarrhoeal Diseases & Acute Respiratory Infections
• Thrust Area 4: Immunisation
– Intensification of Routine Immunisation
– Eliminating Measles and Japanese Encephalitis related deaths
Monday,
September 15,
2014

31. Facility based new born and child care
• Special Newborn Care Units (SNCU)
– states have been asked to set up at least one SNCU in each district. SNCU is 12-20
bedded unit and requires 4 trained doctors and 10-12 nurses for round the clock
services
• Newborn Stabilization units (NBSUs)
– NBSUs are established at community health centres /FRUs. These are 4 bedded units
with trained doctors and nurses for stabilization of sick newborns.
• New Born Care Corners (NBCCs)
– These are 1 bedded facility attached to the labour room and Operation Theatre (OT)
for provision of essential newborn care. NBCC at each facility where deliveries are
taking place should be established.
Monday,
September 15,
2014

32. • Janani suraksha karyakram
– janani Shishu Suraksha Karyakram (JSSK) was launched on 1st June 2011and has
provision for both pregnant women and sick new born till 30 days after birth are
– (1) Free and zero expense treatment,
– (2) Free drugs and consumables,
– (3) Free diagnostics & Diet,
– (4) Free provision of blood,
– (5) Free transport from home to health institutions,
– (6) Free transport between facilities in case of referral,
– (7) Drop back from institutions to home,
– (8) Exemption from all kinds of user charges.
Monday,
September 15,
2014

33. • Integrated management of Neonatal and Child hood illness:
– Improvement in case management skills of health staff
– Improvement in health system
– Improvement in family and community practices
– ASSESS THE CHILD
– CLASSIFY CHILD’S ILLNESS Using colour coded triage system:
Monday,
September 15,
2014

34. • F-IMNCI
– F-IMNCI is the integration of the Facility based Care package with the IMNCI
package
– focuses on providing appropriate skills for inpatient management of major causes of
Neonatal and Childhood mortality such as asphyxia, sepsis, low birth weight and
pneumonia, diarrhea, malaria, meningitis, severe malnutrition in children
– This training is being imparted to Medical officers, Staff nurses and ANMs at
CHC/FRUs and 24x7 PHCs where deliveries are taking place. The training is for 11
days.
Monday,
September 15,
2014

35. • Home Based New Born care:
– ASHA will make visits to all newborns according to specified schedule up to 42 days
of life
– Recording of weight of the newborn in MCP card
– ensuring BCG , 1st dose of OPV and DPT vaccination
– both the mother and the newborn are safe till 42 days of the delivery, and
– registration of birth has been done
Monday,
September 15,
2014

36. • Navjaat Shishu Suraksha Karyakram(NSSK):
– NSSK is a programme aimed to train health personnel in basic newborn care and
resuscitation.
– has been launched to address care at birth issues i.e. Prevention of Hypothermia,
Prevention of Infection, Early initiation of Breast feeding and Basic Newborn
Resuscitation
– The objective of this new initiative is to have a trained health personal in Basic new
born care and resuscitation at every delivery point.
– The training is for 2 days and is expected to reduce neonatal mortality significantly in
the country.
•
Monday,
September 15,
2014

37. • Infant and Young child Feeding:
– Infant and Young Child Feeding is the single most preventive intervention for child
survival. It advocates the following:-
• Early initiation (within one hour of birth) and exclusive breast feeding till 6 months.
• Timely complementary feeding after 6 months with continued breast feeding till the age of
2 yrs.
Monday,
September 15,
2014

38. • Nutrition rehabilitation centres:
– treat severe acute malnutrition amongst children
– Nutritional Rehabilitation Centres (NRCs) are being set up in the health facilities for
inpatient management of severely malnourished children, with counselling of mothers
for proper feeding and once they are on the road to recovery, they are sent back home
with regular follow up.
Monday,
September 15,
2014

39. • Reduction in morbidity and mortality due to acute respiratory tract
infections and diarrheoal diseases.
– Childhood Diarrhoea
• India introduced the low osmolarity Oral Rehydration Solution (ORS), as recommended by
WHO for the management of diarrhea.
• Zinc has been approved as an adjunct to ORS for the management of diarrhea. Addition of
Zinc would result in reduction of the number and severity of episodes and the duration of
diarrhoea.
• New guidelines on management of diarrhoea have been modified based on the latest
available scientific evidence
Monday,
September 15,
2014

40. – Acute Respiratory Infections
• Acute Respiratory Infections forms 19 % of all under five mortalities in India (WHO 2007
report) and along with Diarrhoea are two major killers of under five children.
• Early diagnosis and appropriate case management by rational use of antibiotics remains one
of the most effective interventions to prevent deaths due to pneumonia.
Monday,
September 15,
2014

41. • Supplimentation with Micronutrients:
– Vitamin – A
• The policy has been revised with the objective of decreasing the prevalence of Vitamin A
deficiency to levels below 0.5%,
– the strategy being implemented is:1,00,000 IU dose of Vitamin A is being given at nine months
– Vitamin A dose of 2,00,000 IU (after 9 months) at six monthly intervals up to five years of age
– All cases of severe malnutrition to be given one additional dose of Vitamin A.
Monday,
September 15,
2014

42. • Iron and Folic Acid supplementation:
– To manage the widespread prevalence of anaemia in the country, the policy has been
revised.
– Infants from the age of 6 months onwards up to the age of five years shall receive iron
supplements in liquid formulation in doses of 20mg elemental iron and 100mcg folic
acid per day per child for 100 days in a year.
– Children 6-10 years of age shall receive iron in the dosage of 30 mg elemental iron
and 250mcg folic acid for 100 days in a year.
– Children above this age group would receive iron supplements in the adult dose
Monday,
September 15,
2014

43. Immunization :
Monday,
September 15,
2014

44. • Rashtriya Bal Swasthya Karyakram (RBSK):
– Comprehensive child health care implies assurance of extensive health services for all
children from birth to 18 years of age for a set of health conditions
– These conditions are Diseases, Deficiencies, Disability and Developmental delays
–
– Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative aiming at early
identification and early intervention for children from birth to 18 years to cover 4 ‘D’s
viz. Defects at birth, Deficiencies, Diseases, Development delays including disability
Monday,
September 15,
2014

45. • First level of screening is to be done at all delivery points through existing
Medical Officers, Staff Nurses and ANMs.
• After 48 hours till 6 weeks the screening of newborns will be done by
ASHA at home as a part of HBNC package.
• Outreach screening will be done by dedicated mobile block level teams for
6 weeks to 6 years at anganwadis centres and 6-18 years children at school.
Monday,
September 15,
2014

46. • Family Planning
– Meeting unmet needs for contraception through provisioning of a range of family
planning methods will be prioritized.
– Family planning services would be utilized as a key strategy to reduce maternal and
child morbidities and mortalities in addition to stabilizing population
– Post-partum and post abortion contraception would be a priority. All states would be
encouraged to focus on promotion of spacing methods, especially Intra-Uterine
Contraceptive Devices (IUCDs)
Monday,
September 15,
2014

47. – Male involvement including male sterilization would be promoted.
– Distribution of contraceptives at the doorstep through ASHAs and other channels will
be actively promoted.
Monday,
September 15,
2014

48. • Addressing the Declining Sex Ratio:
– stricter enforcement of the PCPNDT Act, improved monitoring and sensitization of
the medical community, and a greater role for civil society action in addressing son
preference, addressing neglect of the girl child in illness care, observing sex ratios in
hospital admissions for illness in children, and providing proactive support for girl
children through the ASHA and Anganwadi system
• Cross cutting areas:
– BCC and addressing social determinants is complementary to all the above strategies.
– Human resources and infrastructure requirements for RMNCH +A services would be
integrated with the facility strengthening component
Monday,
September 15,
2014

49. Monday,
September 15,
2014
Maternal Mortality rate
Total fertility rate

50. Monday,
September 15,
2014

51. References
• http://nrhm.gov.in/images/pdf/NHM/NRH_Framework_for_Implementation__08
-01-2014_.pdf 25-08-2014; 16.00 hrs
• http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/background.html
26-08-2014: 17.00 hrs
• http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html
25-08-2014;17.30 hrs
• http://nrhm.gov.in/images/pdf/programmes/RBSK/For_more_information.pdf 26-
08-2014;15.00hrs
• J Kishore. National Health Programs of India. 10th ed. Century Publication. New
Delhi. 2012
• Park K. Textbook of Preventive and Social Medicine. 21st ed. Jabalpur(India):
Banarsidas Bhanot Publishers; 2011
Monday,
September 15,
2014

52. Monday,
September 15,
Ravi Varma (1848 – 1906) 2014