INDIA Dr. I.Selvaraj B.Sc., M.B.B.S., D.P.H., D.I.H.,PGCH&FW(NIHFW) INDIAN RAILWAY MEDICAL SERVICE Post Graduate student in Community Medicine(M.D)Department of Community Medicine / SRMC & RI (DU )
MILES STONE IN MCH CARE IN INDIA• 1880 – ESTABLISHMENT OF TRAINING OF DAIS IN AMRITSTAR• 1902 - 1st MIDWIFERY ACT TO PROMOTE SAFE DELIVERY• 1930 - SETTING UP OF ADVISORY COMMITTEE ON MATERNAL MORTALITY.• 1946 - BHORE COMMITTEE RECOMMENDATION ON COMPREHENSIVE & INTEGRATED HEALTH CARE• 1952 – PRIMARY HEALTH CENTER NET WORK & FAMILY PLANNING PROGRAMME• 1956 – MCH CENTERS BECOME INTEGRAL PART OF PHCS• 1961 - DEPARTMENT OF FAMILY PLANNING CREATED• 1971 – MTP ACT• 1974 – FAMILY PLANNING SERVICES INCORPORATED IN MCH CARE• 1977 – RENAMING FAMILY PLANNING TO FAMILY WELFARE• 1978 – EXPANDED PROGRAMME ON IMMUNIZATION• 1985 – UNIVERSAL IMMUNIZATION PROGRAMME• 1992 – CHILD SURVIVAL& SAFE MOTHERHOOD PROGRAMME• 1996 – TARGET FREE APPROACH• 1997 – RCH PROGRAMME PHASE-1• 2005 – RCH PROGRAMME PHASE-2
IMR MMR %BPL INDIA 70/1000 408/1LLB 26.1 KERALA 14/1000 87/1LLB 12.72 UP 84/1000 707/1LLB 31.15 BIHAR 63/1000 707/1LLB 42.60 RAJASTHAN 81/1000 607/1LLB 15.28 TN 19. 2/1000 130/1LLB 21.12SOURCE: NATIONAL HEALTH POLICY 2001
MATERNAL MORTALITYDeath of a woman while pregnant orwith in 42 days of termination ofpregnancy irrespective of duration &site of pregnancy from any causerelated to or aggravated by pregnancyor its management but not fromaccidental or incidental causes.
MAJOR CAUSES OF M.M.R• DIRECT CAUSES• HEMORRHAGE – 29.6%• PUERPERAL COMPLICATION – 16.1%• OBSTRUCTED LABOUR – 9.5%• ABORTIONS – 8.9%• TOXAEMIA OF PREGNANCY 8.3%• INDIRECT CAUSES• Anaemia• Pregnancy with TB• Pregnancy with malaria• Pregnancy with viral hepatitis
MMR IN SELECTED COUNTRIES (2000)COUNTRY MMR(1L/LB)INDIA 407SRI LANKA 92BANGALADESH 380NEPAL 740CHINA 56JAPAN 10SINGAPORE 15UK 14USA 14SWITZERLAND 7
ESTIMATED MMR –MAJOR STATES –INDIA(2000) STATES MMR/1L LB ANDHRA PRADESH 154 BIHAR 451 GUJARAT 29 KARNATAKA 195 KERALA 195 MADHYA PRADESH 498 RAJASTAN 677 TAMIL NADU 76 UTTAR PRADESH 707
DISPARITY OF MATERNAL DEATH BETWEEN DEVELOPED & DEVELOPING COUNTRIES• BARRIER TO RECEIVE TIMELY & GOOD QUALITY CARE• BARRIER OF AVAILABILITY AND ACCESSIBILITY OF SERVICES• POLITICAL BARRIER• GEOGRAPHICAL BARRIER• CULTURAL BARRIER• WOMEN’S LITERACY AND WOMEN EMPOWERMENT• TIME BARRIER• ECONOMIC BARRIER• BARRIER TO HAVE HEALTH PERSONNEL AT GRASS ROOT LEVEL
Objectives· Reduction of Maternal Morbidity and Mortality (MMR) · Reduction of Infant Morbidity and Mortality (IMR) · Reduction of Under 5 Morbidity and Mortality (U5MR) · Promotion of adolescent health · Control of reproductive tract infections and sexually transmitted infections.
• The first phase of the programme had started from 1997• To bring down the birth rate below 21 per 1000 population• To reduce the infant mortality rate below 60 per 1000 life born• To bring down the maternal mortality rate below 400 per one lakh.• Eighty per cent institutional delivery,• 100 per cent antenatal care• and 100 per cent immunization ofchildren
Camp Oriented . Client Oriented• Sterilization Camps • Full Range of RCH Services• IUD Camps • Need Based• Immunisation Camps
Target Oriented Goal Oriented Performance by Performance by Numbers Quality• Top Down • Bottom up • Client Need Based• Target Driven • Community Participation• To the Govt. System • To the Clients, Community
Safe Motherhood Services- Essential Care for All Child Survival- Early Identification of Complications Services- Emergency Services those who are in need Family Welfare- Increased access to Healthy Prevention and Contraceptives Mother Management of &- Safe Abortion Child RTI /STI Services Adolescent Health Care and Family Life Education
COMPONENTS OF RCH PROGRAMME• Prevention and management of unwanted pregnancy• Maternal care that includes antenatal, delivery, and postpartum services• Child survival services for newborns and infants• Management of reproductive tract infections and sexually transmitted infections
REPRODUCTIVE HEALTH ELEMENTS• Responsible and healthy sexual behaviour• Intervention to promote safe motherhood• Prevention of unwanted pregnancy• To increase accessibility of contraceptives• Safe abortions• Pregnancy and delivery services• Management of RTI/STD• Referral facility by government/private sector for pregnant women at risk• Reproductive health services for adolescents• Screening and treatment of infertility, cancer & other gynecological disorders
CHILD SURVIVAL ELEMENTS• Essential New Born Care• Prevention and management of vaccine preventable disease• Urban measles campaign• Neonatal tetanus elimination• Surveillance of vaccine preventable diseases• Cold chain system• Polio eradication : pulse polio programme• ARI control programme• Diarrhea control programme and ORS programme• Prevention and control of Vitamin A deficiency among children• Baby Friendly Hospital Initiative (BFHI)
STRATEGY• BOTTOM-UP PLANNING• COMMUNITY NEED ASSESSMENT APPROACH• DECENTRALISED PARTICIPATORY PLANNING & IMPLEMENTATION• STRENGTHENING INFRASTUCTURE• INTEGRATED TRAINING PACKAGE• IMPROVED MANAGEMENT SYSTEM• INTERVENTIONS• MONITORING & EVALUATION
ANTE NATAL CARE• Early registration of pregnancies (12 – 16 weeks)• Minimum 3 antenatal visits (20,32,36 weeks) check- ups• Anaemia prophylaxis ( Iron and Folic acid tablets)• Two doses of TT• Minimum investigations( Weight, B.P,Blood group, Rh typing, Urine examination,VDRL,HIV (TRIDOT TEST)• Identification of high risk group, Early detection of complication of pregnancy & timely , safely referral to FRU• Treatment of worm infestation with Mebendazole• Health education on diet, breast feeding, care of breast, personnel hygiene during pregnancy,& family planning
REFERAL1. BLEEDING 1.FIRST LEVEL REFERRAL CENTER2. OBSTRUTED LABOUR 2.COMMUNITY HEALTH CENTER/DISTRIC HOSPITAL1. SEPSIS2. TOXAEMIA PRIMARY HEALTH3. ABORTION CENTER1.ANAEMIA SUB CENTER2.FAMILY PLANNING
COMPLICATIONS DURING ANTE-NATAL, INTRA NATAL, AND POST NATAL PERIOD & WHERE TO REFER AVERAGE TIME INSTITUTION TO COMPLICATIONS FROM ONSET TO WHICH TO BE DEATH REFRRED1.APH 12 HRS FIRST LEVEL2.PPH 2 HRS REFERAL CENTERSEVERE 2 DAYS PHC/CHCTOXAEMIARUPTURED 24 HRS FLRCUTERUSOBSTRUCTED 3 DAYS FLRCLABOURSEPSIS ( AFTER 6 DAYS PHC/ CHC/FLRCABORTION,DELIVERY)SEVERE ANAEMIA 2 HRS TO 1 DAY FLRC( CHF IN LABOUR)
PACKAGES OF SERVICES AT FRU •VACCUM EXTRACTIONS •ADMINISTRATION OF ANAESTHESIA •BLOOD TRANSFUSION •CASEAREAN SECTION •MANUAL REMOVAL OF PLACENTA •CARRY OUT SUCTION CURETTAGE FOR INCOMPLETE ABORTION •INSERTION OF INTRAUTERINE DEVICES •STERILIZATION OPERATION
TYPES OF KIT for FRU•Kit-E – Laparotomy set•Kit-F - Mini– Laparotomy set•Kit-G – IUD insertion set•Kit-H – Vasectomy set•Kit- I – Normal delivery set•Kit- J – Vacuum extraction set•Kit- k – Embryotomy set•Kit- L – Uterine evacuation set•Kit-M – Equipment for anesthesia•Kit-N- Neonatal resuscitation set•Kit-O- Equipment and reagent for blood test•Kit-P – Donor blood transfusion set
INTRANATAL CARE• Delivery by trained personnel (100%)• Institutional delivery (80%)• Care at birth ( Five cleans: Clean Birth Canal,Clean surface for delivery,Clean Hands,Clean Cutting, & Clean Cord)
POST NATAL CARE• 3 post natal check-ups of mothers after delivery• Breast feeding – early & exclusive breast feeding• Spacing – minimum 3 years between two pregnancies
NEW STRATEGY• EMPOWERED ACTION GROUP HAS BEENCONSITUTED ON 20.03.2001• TRAINING OF DAIS IN 156 DISTRICTS 18 STATES/UTs 2001-2002• RCH CAMPS & RCH OUT REACH SCHEME• GADCHIROLI MODEL TO TAKE CARE OF HOMEBASED NEONATEL CARE IN 2002• KANGAROO MOTHER CARE TO TAKE CARE OFLOW BIRTH WEIGHT INFANTS• BORDER DISTRICT CLUSTER STRATEGY – 49DISTRICTS/17 STATES• INTEGRATED MANAGEMENT OF CHILDHOODILLNESS STRATEGY TO TAKE CARE OF SICKNEWBORNS
STEPS TO REDUCE MATERNAL MORTALITY• HEALTH SECTOR ACTIONS Basic antenatal , intra natal &post natal care. skilled attendants @ every birth. EOC & Comprehensive obstetric care. Prevention of unwanted pregnancy &unsafe abortions. Joint consultations -medical disorders. Maternal mortality audit .
STEPS TO REDUCE• COMMUNITY , SOCIETY & FAMILY ACTIONS .• HEALTH PLANNERS /POLICY MAKERS ACTIONS community education ,motivation. Strengthen referral system. management protocols for obstetric emergencies. CME – Improve quality & standard of care. Maternal mortality audit .
STEPS TO REDUCE• LEGISLATIVE & POLICY ACTIONS Girl children & adolescents : nutrition , cducation ,economic opportunities. Remove barriers to access health care. Cost Socio cultural factors Safe abortions & post abortion care -MVA Remove social inequalities- gender , age marital status.
ACHIVEMENT OF H & FW INDICATORS IN TAMILNADU( 1997-2002)• LIFE EXPECTANCY AT BIRTH – 65• CRUDE BIRTH RATE – 19.2• CRUDE DEATH RATE – 7.9• NATURAL GROWTH RATE – 1.1• INFANT MORTALITY RATE – 51• UNDER FIVE MORTALITY RATE – 15.1( R )9.7( U )• MATERNAL MORTALITY RATE – 1.3• TOTAL FERTILITY RATE – 1.95• COUPLE PROTECTION RATE – 51.6• MEAN AGE AT MARRIAGE – 21.2• ANTE NATAL CARE – 98.5%• POST NATAL CARE – 90%• INSTITUTIONAL DELIVERY – 87.6%• DELIVERY BY TRAINED STAFF – 98%• PNMR –43/1000• NNMR – 38/1000• % OF LOW BIRTH WEIGHT BABIES –17%• AVERAGE BIRTH WEIGHT OF BABIES – 2.7 KG• STILL BIRTH RATE – 11.7/1000• IMMUNIZATION COVERAGE –100%
World Health Day 2005 Slogan Make Every Mother And Child CountReflects that health of women and children should be given higher priority at all levels of health care system.Every one is accountable for health of mothers & children
THE 5 YEAR PHASE OF RCH IIVISION To bring about outcomes as envisioned in the1. Millennium Development Goals2. The National Population Policy 2000 (NPP 2000)Goals3. The Tenth Plan Goals4. The National Health Policy 20025. and Vision 2020 India
1. MATERNAL HEALTHa) 260 Primary Health Centres are proposed to be taken up for improving access to Essential Obstetric and New Born Care services round the clock in TN. All CHC, & 50% PHCs to be made functional for 24 hrs delivery services,& 2000 FRU are proposedb) Improving quality of antenatal, neonatal and postnatal care by providing increased number of antenatal checkups, fixed day antenatal clinics, linking visits of neonates with postnatal care, empowering the VHNs in performing obstetric first aid and newborn care.c) Improvement of the referral networking systems by establishing emergency help line.d) Regular conduct of blood donation camps for the continued availability of blood in the blood banks.e) Universalizing the concept of birth companionship during the process of labour in all health facilities conducting deliveries.f) Operationalisation of maternal death audit to address the
INFANT AND CHILD HEALTHa. Reduction of new-born deaths, infant deathsand child deaths by providing continuous healthcare and strengthening of new-born careinfrastructure facilities.b. Organizing counselling sessions for themothers.c. Implementing integrated management ofneonatal and childhood illness as a pilot initiativein selected districts in Tamil Nadu.d. Operationalising infant death/stillbirth verbalautopsy.e. Addressing the issue of female infanticide andfoeticide.
3. ADOLESCENT HEALTH.a) Focusing adolescents as receivers andproviders of knowledge and function as linkvolunteers in the community.b) Utilising the services of trained adolescentsfor propagating Indian System of Medicines.c) Broadcasting and Telecasting ofprogramme by AIR/TV focusing adolescent,gender and health related subjects.d) Formation of co-ordination committee atthe district level and monitoring committee atthe State level for overseeing the AIR/TVprogramme.
FAMILY WELFAREa)While sustaining the ongoing family welfareinterventions in all districts, 19 districts with Higherorder births will be targeted for intensifiedinterventions.b) Social marketing programme for condom and otherhealth commodities, promotion of IUD insertions,familiarizing the concept of one-stop Family WelfareCentre.c) Increasing access to safe abortion services bypopularising manual vacuum aspiration (MVA)technique.d) Establishment of one-stop family welfare services atComprehensive Emergency Obstetric and New BornCare (CEMONC) Centres.e) Popularizing No Scalpel Vasectomy.
5. Reproductive tract infections / Sexuallytransmitted infections / Cancer control.a) Establishment of Reproductive TractInfection / Sexually Transmitted Infection,early Cancer detection clinics .b) Strengthening RCH outreach services.c) RTI/STD clinic in selected 70 primaryhealth centers
Infrastructure strengthening for servicedeliverya) Construction of HSC buildings where HSCs arecurrently functioning in rented premisesb) Rebuilding HSCs which are unfit for occupation.c) Taking up of repairs/renovation and provision ofwater supply/electrical works to PHCs/HSCs.d) Need-based supply of equipment/furniture to theHSCs and PHCs as per the standard list including gasconnections.e) Provision of Cell phones to HSCs where largenumber of deliveries take place.f) Provision of telephones to PHCs
TRAININGa) Skill upgradation training with focuson improving/upgrading the skills ofhealth care providers.b) Integrated skill training for peripheralhealth functionaries such as VHNs, SHNs,medical officers and health inspectors.c) Improving managerial andcommunication skills of health staff.
BEHAVIOURAL CHANGE COMMUNICATION(BCC)a) Social mobilisation activity against femaleinfanticide and foeticide by preventivecounselling.b) Formation of HSC, Block, District levelcommittees for saving female babies.c) Conducting of Kalaipayanam (travellingstreet theatre) to promote social mobilizationand to improve health care among the targetpopulationd) Telecasting of TV serials, Radio broadcasts,wall paintings, hoardings and glow signs forpopularizing health and reproductive healthmessages in important places.
HEALTH MANAGEMENT INFORMATION SYSTEMSIntroduction of IT-enabled HMIS for planning and monitoring health services at the State/District /Block levelsSTRENGTHENING OF TEACHING INSTITUTIONSStrengthening the facilities at teaching institutions for providing optimum obstetric, family welfare, neonatal child health services.ESTABLISHING URBAN HEALTH POSTSTo provide an integrated and sustainable system for primary health care service delivery catering to the requirements of urban slum population and other vulnerable groups
HEALTH FINANCINGThe health care expenditure in Indiacurrently stands at 6.1% of GDP. Theprivate out of pocket expenditurebeing 4.7% of Gross DomesticProduct (GDP). The total governmentexpenditure on family welfare hasshown an increasing trend from 4.9billion in fifth plan (1974-79) to Rs.271.25 billion in the tenth plan(2002-07)
ACCESSIBILITY INDICATOR•No. of eligible couples registered/ANM•No. of Antenatal Care sessions held as planned•% of sub Centers with no ANM•% of sub Centers with working equipment ofANC•% ANM/TBA without requisite skill•% sub centers with DDKs•% of sub centers with infant weighing machine•% subcenters with vaccine supplies•% sub centers with ORS packets•% sub centers with FP supplies
QUALITY INDICATOR•% Pregnancy Registered before 12 weeks•% ANC with 5 visits•% ANC receiving all RCH services•% High risk cases referred•% High risk cases followed up•% deliveries by ANM/TBA•%PNC with 3 PNC visits•% PNC receiving all counselling•% PNC complications referred•% Eligible couple offered FP choices•% women screened for RTI/STDs•% Eligible couple counselled for prevention of RTI/STDs•% ADD given ORS•% ARI treated•% children fully immunized
IMPACT INDICATOR•% DEATHS FROM MATERNAL CAUSES•MATERNAL MORTALITY RATIO•PREVALENCE OF MATERNAL MORBIDITY•% LOW BIRTH WEIGHT•NEO-NATAL MORTALITY RATIO•PREVALENCE OF POST NATAL MATERNAL MORBIDITY•% BABY BREAST FEED WITHIN 6 HRS OF DELIVERY•COUPLE PROTECTION RATE•PREVALENCE OF TERMINAL METHOD OFSTERILIZATION•PREVALENCE OF SPACING METHOD•% ABORTION RELATED MORBIDITY•PREVALENCE OF ADD•PREVALENCE OF ARI•PREVALENCE OF RTI/STDs