The document discusses India's RMNCH+A (Reproductive, Maternal, Newborn, Child Health Plus Adolescent) approach, which aims to provide integrated health services across different life stages through a continuum of care. Key aspects of the approach include reducing mortality and malnutrition, increasing immunization coverage, and strengthening service delivery through community health workers. Progress is monitored using indicators tracked in scorecards that measure coverage of important interventions like antenatal care, institutional deliveries, postnatal checks, and child nutrition. The approach emphasizes addressing the needs of vulnerable groups like adolescent mothers through new initiatives for maternal and newborn care, child health, family planning and adolescent health.

1. RMNCH+A
A continuum of Care
Approach
Dr Mohan Lal
Professor
Department of Community Medicine,
Govt. Medical College, Amritsar

2. Outline of Presentation
• Reproductive , Maternal , New born , child Plus
Adolescent (RMNCH+A)
• Pregnancy and Child Birth
• Newborn & Child Health
• Adolescents
• Reproductive health & Family planning
• Monitoring

3. RCH to RMNCH+A??
• Launched in February,2013
• Continuum of care: Gives integrated packages of
services for different stages of life.
• 5 impact indicators under 5 pillars to be
implemented together, at same time, with high
quality and coverage
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4. 12th plan MCH Goals
• Reduction in MMR to 100 per 100,000 live births
• Reduction in IMR to 25 per 1000 live births
• Reduction in TFR to 2.1
• Reduce by half under nutrition in children under 3 years(46% to
23%)
• Reduce by half anemia among reproductive aged women (56% to
28%)
• Improve child Sex ratio (914 to 950)

7. Appropriately directs the states to focus their efforts on
the most vulnerable population & disadvantaged groups
in the country.
Adolescent mothers:
High risk pregnancy & chances of dying are twice than in
women over age 20
Prevalence of Neonatal mortality (54.2/ 1000 LB) is higher
among adolescent mothers (NFHS III, 2005-06)
Anaemia is a major contributory factor in maternal
deaths due to haemorrhage
Why RMNCH+A approach?

8. New initiatives like the use of Score Card
to track the performance

9. 5x5 matrix for high impact RMNCH+A
interventions
• Reproductive Health
i. Focus on spacing methods,
particularly PPIUCD at high case
load facilities
ii. Focus on interval IUCD at all
facilities including subcentres on
fixed days
iii. Home delivery of
contraceptives(HDC) and Ensuring
Spacing at Birth(ESB) through
ASHA’s
iv. Ensuring access to Pregnancy
Testing Kits
v. Maintaining quality sterilization
services
• Maternal Health
i. Use MCTS to ensure early registration
of pregnancy and full ANC
ii. Detect high risk pregnancies
iii. Equip delivery points with highly
trained human resource and ensure
equitable access to EmOC services
through first referral units
iv. Review maternal, infant and child
deaths for corrective actions
V. Identify villages with high numbers
of home deliveries
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10. Newborn Health
i. Early initiation and
exclusive breastfeeding
ii. Home based newborn care
through ASHA
iii. Essential new born care
iv. Special new born care units
v. Community level use of
gentamycin by ANM
Child Health
i. Complementary feeding, IFA
supplementation and focus on
nutrition
ii. Diarrhoea management at
community level
iii. Management of pneumonia
iv. Full immunization coverage
v. Rashtriya Bal Swasthya
Karyakram
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11. Janani Shishu Suraksha Karyakram
(JSSK)
• To reduce out-of-pocket expenses related to maternal
and newborn care.
• The scheme implemented across the country entitles all
pregnant women delivering in public health institutions
to absolutely free and no expense normal delivery (3
days), including caesarean section (7 days).
• Similar entitlements are in place for all sick newborn
(first 30 days of life) accessing public health
institutions for treatment.
• Free assured transport (ambulance service) from home
to health facility, inter-facility transfer in case of
referral and drop back is an entitlement

12. Post Natal care
• Postpartum care for mother & baby
• To ensure postpartum care for mothers & newborns,
• 48 hours of stay at the health facility is mandated in case
of institutional delivery.
• Postnatal home visits are made by frontline
workers(ASHA, ANM) irrespective of the place of
delivery for 6 weeks.

13. Contd.
• Misoprostol for prevention of PPH:-
• In places with home deliveries >80 %, 3 tablets of
Misoprostol ( 200mcg.) are given to pregnant women at 8
months of gestation . Taken immediately after delivery .
• Comprehensive safe MTP:-
• MVA facilities to be available at all CHCs and 50 %
PHCs.
• Private & NGOs sector encouraged & frontline workers
trained to provide confidential counseling & promote post
abortion adoption of contraception.

14. Intensified Newborn Action Plan
• Recently launched with goal to achieve single digit Neonatal Mortality
Rate & Still Birth Rate by 2030.
• • Six pillars of interventions include-
• 1. Preconception and antenatal care
• 2. Care during labor and child birth
•
• 3. Immediate newborn care
• 4. Care of healthy newborn
• 5. Care of small & sick newborn
• 6. Care beyond newborn survival

15. Navjaat Shishu Suraksha Karyakram
(NSSK)
• Launched to address issues of care at birth.
• Doctors, ANM and Nurses posted at delivery points
are trained in basic newborn care & resuscitation
for 2 days.
• The saturation of all delivery points with Skilled
Birth Attendance & NSSK trained personnel &
functional Newborn Care Corners are the topmost
priorities.

16. Facility-based care of the sick
newborns:
• Special Newborn Care Units (SNCU) have been
established at District Hospitals and tertiary care hospitals
• The goal is to have one SNCU in each district of the
country and in health facilities with more than 3,000
deliveries per year
• Newborn Stabilization Unit ( NBSU), which is a four-
bedded unit providing basic level of sick newborn care, is
being established at Community Health Centers / First
Referral Units

17. Follow up Services
• Follow up of the sick newborn after discharge
• Sick newborns discharged from health facilities should
be followed up for Developmental Screening & Early
Intervention & also provided special care or treatment
required.
• During these follow ups, counseling on exclusive
breastfeeding, complementary feeding, growth
monitoring, and screening for neuro- developmental
disorders (such as visual, hearing) done.

18. HOME-BASED NEWBORN CARE
SCHEME
• Launched in 2011 to ensure Immediate postnatal care
(especially in the cases of home delivery) & essential
newborn care to all newborns up to the age of 42
days.
• Frontline workers (ASHAs) are trained and
incentivized to provide special care to preterm and
newborns discharged from Special Newborn Care
Units (SNCUs).
• ASHA records weight in MCP card, ensures BCG-
OPV-DPT vaccination, birth registration and maternal
& child health.

19. Immunisation
Goal of universal immunization. Pentavalent vaccine
• A combination vaccine(DPT + Hep-B + Hib).
• New Vaccines • Rotavirus, rubella and inactivated poliovirus
vaccine (IPV) will be made available to all children through
India’s Universal Immunization
• Measles 2nd dose
• JE vaccine is now being provided in two dosages in some
endemic districts across nine states.
• Mission Indradhanush • Launched on December 25, 2014.

20. Integrated management of common
childhood illnesses
• Availability of ORS and Zinc should be ensured at all sub- centers &
with all frontline workers
• Timely and prompt referral of children with fast breathing and/or
lower chest in-drawing should be made to higher level of facilities .
• Training of health service providers (doctors and nurses), especially
those at FRUs and District Hospitals in F-IMNCI

21. Rashtriya Bal Swasthya Karyakram
• This initiative aims to reach children annually in the age group 0-18
years
• Child health screening and early interventions services by mobile
health teams at block level
• These teams will include - at least
• 2 doctors (MBBS /AYUSH qualified) –
• 2 paramedics
• The health screening to detect 4Ds: defects, deficiencies, diseases,
development delays including disabilities

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23. Information & counseling on health
issues:
• Platform to educate & counsel adolescents on behavior
risk modification
• Screening for diabetes & other non-communicable
diseases is proposed
• Service providers (teachers, AWW ANMs ) will be
trained to screen for anxiety, stress, depression, suicidal
tendencies and refer them to appropriate facility
management of mental health disorders

24. Rashtriya Kishor Swasthya Karyakram
(RKSK)
• launched on January 7, 2014.
• Comprehensively address the health needs of adolescents
• Account for over 21% of the country’s population.
• RKSK will include a sharp focus on adolescents’ sexual
health.

25. Adolescent
• The RKSK programme defines an adolescent as a
person within 10-19 years of age, in urban and rural
areas, includes both girls and boys, married and
unmarried, poor and affluent, whether they are in
school or out of school.
• The Rashtriya Kishor Swasthya Karyakram (RKSK)
will bring in several new dimensions, such as –
mental health, nutrition, substance misuse, gender
based violence and non-communicable diseases.
• The programme introduces community based
interventions through peer educators,

26. Intervention Packages Across
Lifestyles
1. National Iron + Initiative, including Weekly Iron &
Folic Acid Supplementation on (WIFS) Program
2.Adolescent friendly health services
3.Promotion of menstrual hygiene practices among
adolescent girls (10-19 years) in rural India

27. Promotion of Menstrual hygiene
• Scheme for promotion of menstrual hygiene among
adolescent girls in rural India:
• This scheme promotes better health and hygiene among
adolescent girls
• Sanitary napkins are provided under NRHM’s brand ‘Free
days’ .
• These napkins are being sold to adolescent girls by
ASHAs.

28. CARE THROUGH REPRODUCTIVE YEARS
PRIORITY INTERVENTIONS
• Community based promotion and delivery of contraceptives
• Promotion of spacing methods
• Sterilization services
• Comprehensive abortion care
• Prevention and management of sexually transmitted
infections
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29. Postpartum I U C D insertion &
sterilization:
• Postpartum IUCD insertion and sterilization
• Placement of trained providers for post-partum
IUCD (PPIUCD) insertion at district and sub-district
hospital level
• Training of Medical Officers in ‘ Minilap ’ for
provision of Post-Partum Sterilization in high case
load facilities
• Counselor ensure healthy timing and spacing between
pregnancies

30. Implementation of (PC&PNDT) Act:
• The mission is to improve sex ratio at birth by regulating pre-
conception & pre-natal diagnostic techniques misused for
sex selection
• Key action: -
• Formation of PC&PNDT cells at state/district level,
• Strengthening of human resources as well as trainings &
establishing appropriate infrastructure at all levels
• Building community opinion against sex selective abortion
and feticide by sensitizing and mobilizing self-help groups and
empowering women

31. Management of RTI and STI
• To be provided at all CHCs and FRUs and at 24 X 7 PHCs .
• For Syndromic management availability of color -coded kits, RPR
testing kits for syphilis and HIV test should be ensured first at
delivery points
• Service providers should be trained in Syndromic management of
STI and RTI.
• Importantly services should be made available across entire
reproductive age group including adolescents, youth & adults.

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Reproductive health Maternal health Newborn
Family planning
commodities: Tubal rings,
IUCD 380A, IUCD 375
Injection Oxytocin Injection Vitamin K
OCP’s, Condoms Tablet Misoprostol Mucous Extractor
Emergency contraceptive
pills (Levonorgestrel 1.5
mg)
Injection
Magnesium
Sulphate
Vaccines-BCG, Oral
Polio vaccine,
Hepatitis B
Pregnancy testing kits
(Nischay)
Tablet Mifepristone
List of Minimum Essential Commodities

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Child health Adolescent health
ORS Tablet albendazole
Zinc Sulphate Dispersable tablets Tablet dicyclomine
Syrup Salbutamol and salbutamol nebulising
solution
Vaccines-DPT, Measles, OPV, HepB
JE(19 States), Pentavalent vaccine
Syrup Vitamin A

34. Health Systems Strengthening
i. Case load based deployment of
human resource at all levels
ii. Ambulance, drugs, diagnostics,
reproductive health commodities
iii. Health education, demand
promotion and behaviour
change communication
iv. Supporting supervision and
monitoring
v. Public grievances redressal
mechanism,client satisfaction
and patient safety 34

35. Score Card is a simple management tool for
converting available HMIS information into
actionable points and assists in comparative
assessment of District and Block performance
•16 indicators selected based on life cycle
approach ( RMNCH+A) representing various
phases
•Overall composite index to measure performance
of the districts
Monitoring progress on RMNCH+A
using Score Card

36. Pregnancy care Child birth
Postnatal care,
newborn & child
health
Reproductive
age group
1st Trimester
registration
4 ANC check-ups
100 IFA intake
Obstetric
complications
attended
TT2 injections
SBA
attending
home
deliveries
Institution
al
deliveries
C-Section
 Newborns
breastfed
within 1 hour
 Women
discharged in
< 48 hours
 Newborns
weighing less
than 2.5 kg
 Newborns
visited within
24hrs of home
delivery
 0 - 11 months
old receiving
Measles
vaccine
Post-partum
sterilization
to total
female
sterilization
Male
sterilization
to total
sterilization
IUD
insertions in
public +
private
accredited
institution
Score Card: HMIS Indicators across the life cycle
Score card: HMIS indicators across life cycle

37. Survey Based score card
• Indicators :
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Mortality 1.Under5 mortality rate
2.Infant mortality rate
3.Neonatal mortality rate
4.Maternal mortality ratio
Fertility 5.Total fertility rate
6.Births to women during age 15-19 out of total
births

38. 38
Nutrition 7.Children with birth weight less than 2.5kg
8.Children under 3yrs who are underweight
Gender 9.Child sex ratio 0-6
Cross-cutting 10.Full immunization Children(12-23mon) receiving
1 dose BCG,3 doses of DPT/OPV/HepB each & 1
dose measles
11.Household having access to toilet facility
12.Couple using spacing method for more than 6
months
Diarrhoea 13.ORT or increased fluids for diarrhoea
Pneumonia 14.Care seeking for ARI in any healthy facility

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Service delivery Woman who received 4+ ANC
Skilled birth attendance
Mothers who received postnatal care from a
doctor/nurse/LHV/ANM/other health personnel
within 2daysof delivery for their last birth
Early initiation of breast feeding(<1hr)
Exclusive breastfeeding for 6 months

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•All India average for each indicator will be taken as a reference
point
•States will be color coded based on:
Mortality indicators, nutrition, fertility:
Green- <20% of national average
Yellow- 20% below & above national average
Red - >20% of national average
Remaining indicators:
Green- >20% of national average
Yellow- 20% below and above national average
Red- <20% of national average

41. THANK YOU
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