OBSTETRIC AND GYNECOLOGICAL NURSING

A SEMINAR ON
NATIONAL HEALTH MISSION
REPRODUCTIVE CHILD HEALTH

1
NATIONAL HEALTH MISSION –REPRODUCTIVE CHILD HEALTH

CENTRAL OBJECTIVE

At the end of the class students will be able to aquire knowledge regarding national health
mission and reproductive child health and will be able to apply this knowledge in their
professional area with a positive attitude.

SPECIFIC OBJECTIVES

At the end of the class students will be able to

 memorize national health mission

 recall the two subdivisions/mission of NHM
 list down the programmes related to maternal and child health
 define reproductive child health
 describe the aims of RCH programme
 listdown the components of RCH programme
 explane RCH phase 1
 describe the interventions in all districts
 discuss the major interventions
 know about empowered action group
 explain RCH phase 2
 discuss the stratagies
 identify new initiatives
 explain janani suraksha yojana
 discuss janani sishu suraksha karyakram
 identify child health components

INTRODUCTION

Human health not only influenced the immunity of society, but also social structures, culture,
politics, and economics. The Union Ministry of Health and Family Welfare is instrumental and

2
responsible for implementation of various programmes on a national scale in the areas of health.
Since India became independent, several measures have been taken under by the National
Government to Improve the health of the people. Program among these measures are the national
health programs, which have been launched by the central government of control/ eradication of
communicable diseases, improvement of environmental sanitation, raising the standard of
nutrition, control of population and improving rural health.

Various International agencies like WHO UNICEF UNFPA world Bank, as also a no. of foreign
agencies like SIDA DANIDA NORAD USAID have been providing technical and material
assistance in the implementation of these programs. The approach is to increase accecss to the
decentralized health system by establishing new infrastructure in deficient areas and by
upgrading the infrastructure in existing institutions.as a part of plan process many different
programmes have been bought together under the overarching of NHM. The government of india
has introduced a series of programmes over the past two decades to address maternal and
newborn health. The RCH programme was based on the diffential approach. Inputs in all the
districts were not kept in uniform. while the care components was same for all districts. The
weaker districts got more support and sophisticated facilities were proposed for relatively
advanced stricts.

CONTENTS

NATIONAL HEALTH MISSION

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.

NATIONAL RURAL HEALTH MISSION (NRHM)

The National Rural Health Mission (NRHM) was launched on 12th April 2005, to provide
accessible, affordable and quality health care to the rural population, especially the vulnerable

3
groups. The Union Cabinet vide its decision dated 1st May 2013, has approved the launch of
National Urban Health Mission (NUHM) as a Sub-mission of an over-arching National Health
Mission (NHM), with National Rural Health Mission (NRHM) being the other Sub-mission of
National Health Mission. NRHM seeks to provide equitable, affordable and quality health care to
the rural population, especially the vulnerable groups. 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.

The Objectives of the Mission

 Reduction in child and maternal mortality

 Universal access to public services for food and nutrition, sanitation and hygiene and
universal access to public health care services with emphasis on services addressing
women’s and children’s health and universal immunization
 Prevention and control of communicable and non-communicable diseases, including
locally endemic diseases.
 Access to integrated comprehensive primary health care.
 Population stabilization, gender and demographic balance.
 Revitalize local health traditions & mainstream AYUSH. Promotion of healthy life styles.
Programmes
 Reproductive and Child Health Programme – II (RCH-II) and the Janani Suraksha
Yojana (JSY) launched.
 Polio eradication programme intensified
 Sterilization compensation scheme launched.
 Accelerated implementation of the Routine Immunization programme taken up.
 Ground work for introduction of JE vaccine completed.
 Ground work for Hepatitis vaccines to all States completed.

4
  Auto Disabled Syringes introduced throughout the country.
 State Programme Implementation Plans for RCH II appraised by the National
Programme Coordination Committee

THE NATIONAL URBAN HEALTH MISSION (NUHM)

The National Urban Health Mission as a sub-mission of National Health Mission 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.

NUHM would endeavour to achieve its goal through:-

 Need based city specific urban health care system to meet the diverse health care needs of
the urban poor and other vulnerable sections.

 Institutional mechanism and management systems to meet the health-related challenges

of a rapidly growing urban population.

 Partnership with community and local bodies for a more proactive involvement in
planning, implementation, and monitoring of health activities.

 Availability of resources for providing essential primary health care to urban poor.

 Partnerships with NGOs, for profit and not for profit health service providers and other
stakeholders.

PROGRAMMES FOR MATERNAL & CHILD HEALTH

5
1992 Child survival and safe motherhood

1997 RCH I

2005 RCH II

2005 NRHM

2013 RMNCH+A Stratagy

2013 National health mission

2014 Indian newborn action plan

REPRODUCTIVE AND CHILD HEALTH PROGRAMME

Reproductive and child health approach has been defined as "people have the ability to
reproduce and regulate their fertility, women are able to go through pregnancy and child birth
safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well
being, and couples are able to have sexual relations, free of fear of pregnancy and of contracting
disease".

The concept is in keeping with the evolution of an integrated approach to the programme aimed
at improving the health status of young women and young children which has been going on in
the country namely family welfare programme, universal immunization programme, oral
rehydration therapy, child survival and safe motherhood programme and acute respiratory
infection control etc. It is obviously sensible that integrated RCH programme would help in
reducing the cost inputs to some extent because overlapping of expenditure would not be
necessary and integrated implementation would optimise outcomes at field level.

The RCH phase-I programme incorporated the components relating child survival and safe
motherhood and included two additional components, one relating to sexually transmitted
disease (STD) and other relating to reproductive tract infection (RTI). The RCH programme was
based on a differential approach. Inputs in all the districts were not kept uniform. While the care

6
components was same for all districts, the weaker districts got more support and sophisticated
facilities were proposed for relatively advanced districts. On the basis of crude birth rate and
female literacy rate, all the districts were divided into three categories. Category ·A having 58
districts, category B having 184 districts and category C having 265 districts. All the districts
were covered in a phased manner over a period of three years. The programme was formally
launched on 15th October 1997.

Aims

 To bring down the birth rate below 21/1000 population

 To reduce the infant mortality rate below 60 per 1000 live birth

 To bring down the maternal mortality rate <400/100000 lakh

RCH phase-I interventions at district level were as follows:

Interventions in all districts

 Child Survival interventions i.e. immunization, Vitamin A (to prevent blindness), oral
rehydration therapy and prevention of deaths due to pneumonia.

 Safe Motherhood interventions e.g. antenatal check up, immunization for tetanus, safe
delivery, anaemia control programme.

 Implementation of Target Free Approach.

 High quality training at all levels.

 IEC activities.

 Specially designed RCH package for urban slums and tribal areas.

 District sub-projects under Local Capacity Enhancement.

 RTl/STD Clinics at District Hospitals (where not available)

7
  Facility for safe abortions at PHCs by providing equipment, contractual doctors etc.

 Enhanced community participation through Panchayats,Women's Groups and NGOs.

 Adolescent health and reproductive hygiene.

Interventions in selected States/Dist.

 Screening and treatment of RTI/STD at sub-divisional level.

 Emergency obstetric care at selected FRUs by providing drugs.

 Essential obstetric care by providing drugs and PHN/ Staff Nurse at PHCs.

 Additional ANM at sub-centres in the weak districts for ensuring MCH care.

 Improved delivery services and emergency care by providing equipment kits, IUD
insertions and ANM kits at sub-centres.

 Facility of referral transport for pregnant women during emergency to the nearest referral
centre through Panchayat in weak districts.

THE COMPONENTS OF RCH I

Essential obstetric care

Essential obstetric care intends to provide the basic maternity services to all pregnant women
through
 Early registration of pregnancy (within 12-16 weeks).
 Provision of minimum three antenatal checkups by anm or medical officer to monitor
progress of the pregnancy and to detect any risk/complication so that appropriate care
including referral could be taken in time.
 Provision of safe delivery at home or in an institution.
 Provision of three postnatal check ups to monitor the postnatal recovery and to detect
complications.

8
Emergency obstetric care
Complications associated with pregnancy are not always predictable, hence, emergency obstetric
care is an important intervention to prevent maternal morbidity and mortality. Under the CSSM
programme 1748 Referral Units were identified and supported with equipment kit E to kit P.
However, these FRUs were not fully operational because of lack of manpower and adequate
infrastructure. Under the RCH programme the FRUs were strengthened through supply of
emergency obstetric kit, equipment kit and provision of skilled manpower on contract basis etc.
Traditional Birth Attendant still plays an important role during deliveries in our society.
24-Hour delivery services at PHCs/CHCs
To promote institutional deliveries, provision has been made to give additional honorarium to the
staff to encourage round the clock delivery facilities at health centres.
Medical Termination of Pregnancy
MTP is a reproductive health measure that enables a woman to opt out of an unwanted or
unintended pregnancy in certain specified circumstances without endangering her life, through
MTP Act 1971. The aim is to reduce maternal morbidity and. mortality from unsafe abortions.
The assistance from the Central Government is in the form of training of manpower, supply of
MTP equipment and provision for engaging doctors trained in MTP to visit PHCs on fixed dates
to perform MTP.

Control of reproductive tract infections (RTI) and sexually transmitted diseases (STD)
Under the RCH programme, the component of RTI/STD control is linked to HIV and AIDS
control. It has been planned and implemented in close collaboration with National AIDS Control
Organization (NACO). NACO provides assistance for setting up RTI/STD clinics upto the
district level. The assistance from the Central Government is in the form of training of the
manpower and drug kits including disposable equipment. Each district is assisted by two
laboratory technicians on contract basis for testing blood, urine and RTI/STD tests.
Immunization
The Universal Immunization Programme (UIP) became a part of CSSM programme in 1992 and
RCH programme in 1997. It will continue to provide vaccines for polio, tetanus, DPT, DT,
measles and tuberculosis. The cold chain established so far will be maintained and additional
items will be provided to new health facilities.

9
Essential newborn care
The primary goal of essential newborn care is to reduce perinatal and neonatal mortality. The
main components are resuscitation of newborn with asphyxia, prevention of hypothermia,
prevention of infection, exclusive breast feeding and referral of sick newborn. The strategies are
to train medical and other health personnel in essential newborn care, provide basic facilities for
care of low birth weight and sick new borns in FRU and district hospitals etc.
Diarrhoeal disease control
In the districts not implementing Integrated Management of Neonatal and Childhood Illness, the
vertical programme for control of diarrhoeal disease will continue. India is the first country in the
world to introduce the low osmolarity Oral Rehydration Solution. Zinc is to be used as an
adjunct to ORS for the management of diarrhoea. Addition of Zinc would result in reduction of
the number and severity of episodes and the duration of diarrhoea. De-worming guidelines have
been formulated. The incidence of diarrhoea is reduced by provision of safe drinking water.

Acute respiratory disease control

The standard case management of ARI and prevention of deaths due to pneumonia is now an
integral part of RCH programme. Peripheral health workers are being trained to recognize and
treat pneumonia. Cotrimoxazole is being supplied to the health workers through the drug kit.
Prevention and control of vitamin A deficiency in children
It is estimated that large number of children suffer from sub-clinical deficiency of vitamin A.
Under the programme, doses of vitamin A are given to all children under 5 years of age. The first
dose (1 lakh units) is given at nine months of age along with measles vaccination. The second
dose (2 lakh units) is given after 9 months. Subsequent doses (2 lakh units each) are given at six
months intervals upto 5 years of age . All cases of severe malnutrition to begiven one additional
dose of vitaminA.
Prevention and control of anaemia in children
Iron deficiency anaemia is widely prevalent in young children. To manage anaemia, the policy
has been revised. Infants from the age of 6 months onwards upto the age of 5 years are to receive
iron supplements in liquid formulation in doses of 20 mg elemental iron and 100 mcg folic acid
per day for 100 days in a year. Children 6 to 10 years of age will receive iron in the dose of 30

10
mg elemental iron and 250 mcg folic acid for 100 days in a year. Children above this age group
would receive iron supplement in the adult dose .
Introduction of Hepatitis B Vaccination
Introduction of Hepatitis B in the National Immunization Programme has been approved by the
Government. Under this project hepatitis B .vaccine will be administered to infants alongwith
the primary doses of DPT vaccine.
Training of dais
A scheme for training of dais was initiated during 2001-02. The scheme is being implemented in
156 districts in 18 states/UTs of the country. The districts have been selected on the basis of the
safe delivery rates being lessthan 30 per cent. The scheme was extended to all the districts of
EAG states. The aim was to train at least one Dai in every village, with the objective of making
deliveries safe.
Empowered Action Group (EAG)
An Empowered Action Group has been constituted in the Ministry of Health and Family
Welfare, with Union Minister for Health and Family Welfare as chairman on 20th March 2001.
As 55 per cent of the increase in the population of India is anticipated in the states of Uttar
Pradesh, Bihar, Madhya Pradesh, Rajasthan, Odisha, Chhattisgarh, Jharkhand and Uttaranchal,
these states are perceived to be most deficient in critical socio-demographic indices. Through
EAG, these states will get focussed attention for different health and family welfare programmes.
District Surveys
There is no regular source of data to indicate the reproductive health status of women. The RCH
programme conducts district based rapid household survey to assess the reproductive health
status of women. The key indicators are:
 Percentage of pregnant women with full ANC
 Percentage of institutional deliveries and home deliveries
 Percentage of home deliveries by trained birth attendant
 Current contraceptive prevalence rate
 Percentage of children fully immunized
 Percentage of unmet need for family planning
 Percentage of household reported visits by health worker in previous 3 months
RCH - PHASE II

11
RCH-phase II began from 1st April, 2005. The focus of the programme is to reduce maternal and
child morbidity and mortality with emphasis on rural health care. The major strategies under the
second phase of RCH are :
1..Essential obstetric care
a. Institutional delivery To promote institutional delivery in RCH Phase II, it was envisaged
that fifty percent of the PHCs and all the CHCs would be made operational as 24-hour
delivery centres, in a phased manner, by the year 2010. These centres would be
responsible for providing basic emergency obstetric care and essential newborn care and
basic newborn resuscitation services round the clock. The experience of RCH phase-I
indicates that giving incentive to health workers for providing round the clock services
did not function well in most of the states. On the contrary there is the experience from
government of Andhra Pradesh and Tamil Nadu, where round the clock delivery and new
born care services could be ensured by providing 3 to 4 staff nurses/ ANM at the PH Cs.
b. Skilled attendance at delivery - It is now recognize globally that the countries which have
been successful in bringing down maternal mortality are the ones where the provision of
skilled attendance at every birth and its linkage with appropriate referral services for
complicated cases have been ensured. The WHO has also emphasized that skilled
attendance at every birth is essential to reduce the maternal mortality in any country.
Guidelines for normal delivery and management of obstetric complications at PHC/CHC
for medical officers and for ANC and skilled attendance at birth for ANM/LHVs have
been formulated and disseminated to the states.
c. The policy decisions : ANMs I LHVs I SNs have now been permitted to use drugs in
specific emergency situations to reduce maternal mortality. They have also been
permitted to carry out certain emergency interventions when the life of the mother is at
stake.
2..Emergency obstetric care
Operationalization of FRUs and skilled attendance at birth are the two activities which go hand
in hand. In view of this, simultaneous steps have been taken to ensure tackling obstetric
emergencies. It has been decided that all the First Referral Units be made operational for
providing emergency and essential obstetric care during the second phase of RCH. The minimum
services to be provided by a fully functional FRU are :

12
  24 hour delivery services including normal and assisted deliveries;
 Emergency obstetric care including surgical interventions like caesarean sections;
 New-born care;
 Emergency care of sick children;
 Full range of family planning services including laproscopic services;
 Safe abortion services;
 Treatment of STI / RTI;
 Blood storage facility;
 Essential laboratory services;
 Referral (transport) services.
There are three critical determinants of a facility being 'declared' as a FRU. They are :
availability of surgical interventions, new-born care and blood storage facility on a 24 hours
basis. To be able to perform the full range of FRU function, a health facility must have the
following facilities :
a) A minimum bed strength of 20-30. However, in difficult areas, as the North-East states
and the underserved areas of EAG states, this could initially be relaxed to 10-12beds
b) A fully functional operation theatre
c) A fully functional labour room
d) An area earmarked and equipped for newborn care in the labour room, and in the ward
e) A functional laboratory
f) Blood storage facility
g) 24 hour water supply and electricity supply
h) Arrangements for waste disposal,
i) Ambulance facilities
3..Strengthening referral system
During RCH phase-I, funds were given to the Panchayat for providing assitance to poor people
in the case of obstetric emergencies. Feedback from the states indicate that there was no active
involvement of Panchayats in running the scheme. Based on these experiences different states
have proposed different modes of referral linkage in RCH Phase IL Some of them have indicated
to involve local self help groups, NGOs and women groups, whereas few others have indicated
to outsource it.

13
New initiatives

1. Training of MBBS doctors in life saving anaesthetic skills for emergency obstetric care :
Provision of adequate and timely emergency obstetric care (EmOC) has been recognized
as the most important intervention for saving lives of pregnant women who may develop
complications during pregnancy or childbirth. The operationalisation of First Referral
Unit at sub-district/CHC level for providing EmOC to pregnant women is a crucial
strategy of RCH-11, which needs focussed attention. The training of MBBS doctors will
be undertaken for only such numbers who are required for the functioning of FRUs and
CHCs, and shall be limited to the requirement of tackling emergency obstetric situations
only. It is not the replacement of thespecialist anaesthetist. Government of India is also
introducing training of MBBS doctors in obstetric management skills. Federation of
Obstetric and Gynaecology Society of India has prepared a training plan for 16 weeks in
all obstetric management skills, including caesarean section operation.

2. Setting up of blood storage centres at FRUs according to government of India guidelines.

JANANI SURAKSHA YOJANA

The National Maternity Benefit scheme has been modified into a new scheme called Janani
Suraksha Yojana (JSY). It was launched on 12th April, 2005. The objectives of the scheme are -
reducing maternal mortality and infant mortality through encouraging delivery at health
institutions, and focusing at institutional care among women in below poverty line families. It is
a 100 per cent centrally sponsored scheme. Under National Rural Health Mission, it integrates
the benefit of cash assistance with institutional care during antenatal, delivery and immediate
post-partum care; This benefit will be given to all women, both rural and urban, belonging to
below poverty line household and aged 19 years or above, up to first two live births. However,
with a view to give special focus in 10 low performing states (states having low institutional
delivery rate), namely Uttar Pradesh, Uttaranchal, Madhya Pradesh, Jharkhand, Bihar, Rajasthan,
Chattisgarh, Odisha, Assam and Jammu & Kashmir, the benefit will be extended upto the third
child if the mother, of her own accord, chooses to undergo sterilization in the health facility
where she delivered, immediately after delivery. The other states are called high performing

14
states. The Accredited Social Health Activist (ASHA) would work as a link health worker
between the poor pregnant women and public sector health insitution in the low performing
states. ASHA would be responsible for making available institutional antenatal as well as
postnatal care. She would also be responsible for escorting the pregnant women to the health
centre. The eligibility of cash assistance is as follows;

 In low performing states (LPS) : All women, including those from SC and ST families,
delivering in government health centres like sub-centre, primary health centre,
community health centre, first referral unit, general wards of district and state hospitals or
accredited private institutions.

 In high performing states (HPS) : Below poverty line women, aged 19 years and above
and the SC and ST pregnant women.

The limitation of cash assistance for institutional delivery is as follows :

 In low performing states : All births, delivered in health centre, government or accredited
private health institutions will get the benefit.

 In high performing states the benefit is only upto 2 live births.

ASHA package is available in all low performing states, North-East states and in tribal districts
of all states .In rural areas it includes the following components : (a) Cash assistance for referral
transport for pregnant women to go to the nearest health centre for delivery (should not be less
than Rs. 250/-); (b) Cash incentive : This should not be less than Rs. 200/- per delivery. ASHA
should get her money after her post-natal visit to the beneficiary, and when the child has been
immunized for BCG; and (c) Balance amount to be paid to ASHA in lieu of her services
rendered by her. The payment should be made at the hospital/health institution itself. The Yojana
subsidizes the cost of caesarean section and for management of obstetric complications, upto Rs.
1500 per delivery to the government institutions, where government specialists are not in
position. In low performing and high performing states, all below poverty line pregnant women
preferring to deliver at home, are entitled to cash assistance of Rs. 500 per delivery, regardless of
age and number of children .

15
Vandemataram scheme

This is a voluntary scheme wherein any obstetric and gynaec specialist, maternity home, nursing
home, lady doctor/MBBS doctor can volunteer themselves for providing safe motherhood
services. The enrolled doctors will display 'Vandemataram logo' at their clinic. Iron and Folic
Acid tablets, oral pills, TT injections etc. will be provided by the respective District Medical
Officers to the 'Vandemataram doctors/ clinics' for free distribution to beneficiaries. The cases
needing special care and treatment can be referred to the government hospitals, who have been
advised to take due care of the patients coming with Vandemataram cards.

Safe abortion services

In India, abortion is a major cause of maternal mortality and morbidity and accounts for nearly
8.9 per cent maternal deaths. Majority of abortions take place outside authorized health services
and/or by unauthorized and unskilled persons. Whether spontaneous or induced, abortion is a
matter of concern as it may lead to complications. Under RCH phase II following facilities are
provided : .

Medical method of abortion : Termination of early pregnancy with two drugs Mifepristone
(RU 486) followed by Misoprostol. They are considered safe under supervision, with appropriate
counselling. Currently its use in India is recommended upto 7 weeks (49 days) of amenorrhoea in
a facility with provision for safe abortion services and blood transfusion. Termination of
pregnancy with RU 486 and Misoprostol is offered to women under the preview of the MTP Act,
1971.

Manual Vacuum Aspiration (MVA) : The department of family welfare has introduced Manual
Vacuum Aspiration (MVA) technique in the family welfare programme. Manual Vacuum
Aspiration is a safe and simple technique for termination of early pregnancy, makes it feasible to
be used in primary health centres or comparable facilities, thereby increasing access to safe
abortion services. The project of introducing the MVA technique has been piloted in
coordination with FOGSI, WHO and respective state governments before being accepted for
implementation by the ministry of health and family welfare.

16
Village Health and Nutrition Day

Organizing Village Health and Nutrition Day once a month at anganwadi centre to provide
antenatal/postpartum care for pregnant women, promote institutional delivery, health education,
immunization, family planning and nutrition services etc.

Maternal death review

Maternal death review as a strategy has been spelt out clearly in the RCH-11. Maternal death
audit, both facility and community based, is an important strategy to improve the quality of
obstetric care and reduce maternal mortality and morbidity. Guidelines and tools for initiating
maternal death review have been formulated .

Pregnancy tracking

The link between pregnancy-related care and maternal mortality is well established. RCH-11
stresses the need for universal screening of pregnant women and providing essential and
emergency obstetric care. Focused antenatal care, birth preparedness and complication readiness,
skilled attendance at birth, care within the first seven days etc. are the factors that can reduce the
maternal mortality .

JANANl-SHISHU SURAKSHA KARYAKRAM (JSSK)

Government of India launched the Janani-Shishu Suraksha Karyakram (JSSK) on 1st June 2011,
a new national initiative, to make available better health facitlies for women and child. The new
initiatives provide the following facilities to the pregnant women;All pregnant women delivering
in public health institutions to have absolutely free and no expense delivery, including caesarean
section. The entitlements include free drugs and consumables, free diet upto 3 days during
normal delivery and upto 7 days for C-section, free diagnostics, and free blood wherever
required. This initiative would also provide for free transport from home to institution, between

17
facilities in case of a referral and drop back home. Similar entitlements have been put in place for
all sick newborns accessing public health institutions for treatment till 30 days· after birth. The
scheme has now been extended to cover the complications during ANC, PNC and also sick
infants. The scheme is estimated to benefit more than 12 million pregnant women who access
government health facilities for their delivery. Moreover, it will motivate those who still choose
to deliver at their homes to opt for institutional deliveries.

Child health components

The strategy for child health care, aims to reduce underfive child mortality through interventions
at every level of service delivery and through improved child care practices and child nutrition.

Nutritional rehabilitation centres (NRCs)

Severe acute malnutrition is an important contributing factor for most deaths among children
suffering from common childhood illness such as diarrhoea and pneumonia. Deaths among these
malnourished children are preventable, provided timely and appropriate actions are taken. NRCs
are facility based units providing medical and nutritional care to severe acute malnutrition
(SAM) children under 5 years of age who have medical complications. In addition special focus
is on improving the skill of mothers on child care and feeding practices so that the child
continues to get adequate care at home. The services provided at the NRCs include :

 24 hours care and monitoring of the child;

 Treatment of medical complication;

 Therapeutic feeding;

 Sensory stimulation and emotional care;

 Counselling on appropriate feed, care and hygiene; and

 Demonstration and practice-by-doing on the preparation of energy dense food using

locally available, culturally acceptable and affordable food items.

18
Integrated Management of Neonatal and Childhood Illness (IMNCI)

IMNCI strategy is one of the main intervention under the RCH II/ NRHM. The strategy
encompasses a range of interventions to prevent and manage the commonest major childhood
diseases.

Pre-service IMNCI

Pre-service IMNCI has been accepted as an important strategy to scale up IMNCI by Govt. of
India and is being included in the curriculum of medical colleges of the country. This will help in
providing the much needed trained IMNCI manpower in the public and private sector.

Facility based IMNCI (F-IMNCI)

F-IMNCI is the integration of the facility based care package with the IMNCI package, to
empower the health personnel with the skill to manage new born and childhood illness at the
community level as well as the health facility. It focusses on providing appropriate inpatient
management of the major causes of neonatal and childhood mortality such as asphyxia, sepsis,
low birth weight, pneumonia, diarrhoea, malaria, meningitis and severe malnutrition in children.
The master trainers at state and district level are paediatricians from tertiary hospitals and
medical colleges .

Facility based newborn care

As more sick children are screened at the peripheries through IMNCI and referred to the health
facilities, care of the sick newborn and child at CHCs, FRUs, district hospitals and medical
college hospitals assumes priority. Equipping the facilities to provide the requisite level of care
and simultaneously enhancing the capacity of the medical officers at these facilities to handle
such cases thus becomes important. The setting up of SNCUs at district hospitals, stabilization
units at CHCs, and newborn care corners at all facilities offering delivery facilities, is thus a key
activity .

Newborn Care Corner (NBCC)

19
NBCC is a space within the delivery room in any health facility where immediate care is
provided to all newborns at birth. This area is MANDATORY. for all health facilities where
deliveries are conducted. As of March 2014, about 13,653 NBCCs are operational in the country.

Newborn Stabilization Unit (NBSU)

NBSU is a facility within or. in close proximity of the maternity ward where sick and low bir.th
weight new.borns can be cared for during short periods. All FRUs/CHCs need to have a neonatal
stabilization unit, in addition to the newborn care corner: It requires space· for 4 bedded unit and
two beds in post-natal ward for rooming-in. As of March 2014, 1, 737 NBSUs are functional in
the country.

Special Newborn Care Unit (SNCU)

SNCU is a neonatal unit in the vicinity of the labor room which is to provide special care (all
care except assisted ventilation and major surgery) for sick newborns. Any facility with more
than 3,000 deliveries per year should have an SNCU (most district hospitals and some sub-
district hospitals would fulfil this criteria). The minimum recommended number of beds for an
SNCU at a district hospital is 12. However, if the district hospital conducts more than 3,000
deliveries per year, 4 beds should be added for each 1~000 additional deliveries. A 12 bedded
unit will require 4 additional adult beds for the step down~ As of March 2014, 507 SNCUs are
functional in the. country.

Triage of sick newborns

Triage is sorting of neonates to rapidly screen sick neonates for prioritizing management.

Criteria for admission to nbsu

Newborn presenting with any of the following signs to a facility with neonatal stabilization unit
requires admission for initial stabilization and transfer to SNCU :

 Apnea or gasping Respiratory distress (Rate> 70/min with severe retractions/grunt)

20
  Hypothermia <35.4°C

 Hyperthermia (>37.5°C)

 Central cyanosis

 Shock (cold periphery with capillary filling time (CFT) 3 seconds and weak and fast
pulse)

 Significant bleeding that requires blood or component transfusion

Newborns, who after assessment and stabilization, can be managed at stabilization unit

 Newborns with respiratory distress, having respiratory rate 60-70/min without grunting or
retractions (for observation and oxygen therapy)

 Newborns with gestation less than 34 weeks or weight < 1800 g (for observation and
assisted feeding)

 Newborns with hypothermia and hyperthermia who are haemodynamically stable after
initial stabilization

 Newborns with jaundice requiring phototherapy

 Neonates with sepsis who are haemodynamically stable, for observation and antibiotic
therapy.

Others would require referral to an SNCU after stabilization, if an SNCU and appropriate
referral is available in the district.

Criteria for admission to SNCU

Criteria for admission to SNCU and criteria for transfer to step-down unit and discharge are as
follows :

21
1 . Any newborn with following criteria should be immediately admitted to the SNCU :

 Birth weight < 1800 g or gestation <34 weeks

 Large baby ( >4.0 kg)

 Perinatal asphyxia

 Apnea or gasping

 Refusal to feed

 Respiratory distress (rate>60/min or grunt/ retractions)

 Severe jaundice (appears <24 hrs/stains palms and soles/lasts> 2 weeks)

 Hypothermia <35.4°C, or hyperthermia (>37.5°C)

 Central cyanosisShock (cold periphery with CFT>3 seconds, and

 weak and fast pulse}

 Newborn accepting breast-feeds well

 Newborn has documented weight gain for 3

 Coma, convulsions or encephalopathy consecutive days; and the weight is more than 1.5
kg

 Abdominal distension

 Diarrhoea/ dysentery

 Bleeding

 Major malformations

22
Criteria for transfer from SNCU to the Step-Down

 Newborn whose respiratory distress is improving and does not require oxygen
supplementation to maintain saturation

 Newborn on antibiotics for completion of duration of therapy

 Low birth weight newborn (less than 1800 g}, who are otherwise stable (for adequate
weight gain}

 Newborn with jaundice requiring phototherapy but otherwise stable

 Newborn admitted for any condition, but are now thermodynamically and
hemodynamically stable

Criteria for discharge from SNCU

 Newborn is able to maintain temperature without radiant warmer

 Newborn is haemodynamically stable (normal CFT, strong peripheral pulse}

 Primary illness has resolved

 In addition to the above, mother should be confident of taking care of the newborn at
home.

Home based newborn care (HBNC) :

 Home based newborn care is aimed at improving newborn survival. The strategy of
universal access to home based newborn care must complement the strategy of
institutional delivery to achieve significant reduction in postpartum and neonatal
mortality and morbidity. The providers of service include anganwadi workers, ANM,
ASHA and the medical officer. However, ASHA is the main person involved in home
based newborn care. The major objective of HBNC is to decrease neonatal mortality and
morbidity through :

23
 The provision of essential newborn care to all newborns and the prevention of
complications.

Early detection and special care of preterm and low birth weight newborns.

Early identification of illness in the newborn and provision of appropriate care and
referral.

Support the family for adoption of healthy practices and build confidence and skills of the
mother to safeguard her health and that of the newborn.

The responsibilities of ASHA for home based newborn care are as follows:

1..Mobilize all pregnant mothers and ensure that they receive the full package of antenatal care.

2..Undertake birth planning and birth preparedness with the mother and family to ensure access
to safe delivery.

3..Provide newborn care. through a series of home visits which include the skills for:

 Weighing the newborn,

 Measuring newborn temperature,

 Ensuring warmth

 Supporting exclusive breast-feeding by teaching the mother proper positioning and

attachment for initiating and maintaining breast-feeding,

 Diagnosing and counselling in case of problems with breast-feeding,

 Promoting hand-washing,

 Providing skin, cord and eye care,

24
  Health promotion and counselling mothers and families on key messages on newborn
care which includes discouraging unhealthy practices such as early bathing, and bottle
feeding,

 Ensuring prompt identification of sepsis or other illnesses.

4.. Assessing if the baby is high-risk (preterm or low birth weight), through the use of protocols
and managing such LBW or preterm babies through Increasing the number of home visits,
Monitoring weight gain, Supporting and counselling the mother and family to keep the baby
warm and enabling frequent and exclusive breast-feeding,

5.. Detect signs and symptoms of sepsis, provide first level care and refer the baby to an
appropriate centre. If the family is unable to go, ASHA should ensure that the ANM visits sick
newborn on a priority basis.

6.. Recognize postpartum complications in the mother and refer appropriately.

7.. Counsel the couple for family planning.

8. Provide immediate newborn care, in case of those deliveries that do not occur in institutions
(home deliveries and deliveries occurring on the way to the institution). ASHA will make visits
to all . newborns according to specified schedule upto 42 days of life. The schedule of visit is as
follows :

Navjat Shishu Suraksha Karyakram (NSSK)

NSSK is a programme aimed to train health personnel in basic newborn care and resuscitation. It
has been launched to address care at birth issue i.e. prevention of hypothermia, prevention of
infection, early initiation of breast-feeding and basic newborn resuscitation. The objective of the
new initiative is to have a trained health person in basic newborn care and resuscitation unit at
every delivery point .

Integrated management of neonatal and childhood illness (IMNCI)

25
Integrated management of childhood illness (IMCI) The extent of childhood morbidity and
mortality caused by diarrhoea, ARI, malaria, measles and malnutrition is substantial. Most sick
children present with signs and symptoms of more than one of these conditions. This overlap
means that a single diagnosis may not be possible or appropriate, and treatment may be
complicated by the need to combine for several conditions. An integrated approach to manage
sick children is, therefore, necessary. IMCI is a strategy for an integrated approach to the
management of childhood illness as it is important for child health programmes to look beyond
the treatment of a single disease. This is cost effective and emphasizes prevention of disease and
promotion of child health and development besides provision of standard case management of
childhood illness. In the Indian context this strategy is quite pertinent considering the recent
evidence from NFHS-III report highlighting that ARI (17 %), diarrhoea (13 %), fever (27 %) and
under-nutrition (43 %) were the commonest morbidities observed in the children aged under 3
years. Coverage of measles vaccination in children between 12-23 months is also low. An
integrated approach to address these major childhood illnesses seems to be an effective strategy
to promote child health in this country. The Indian version of IMCI has been renamed as
Integrated Management of Neonatal and Childhood Illness (IMNCI). It is the central pillar of
child health interventions under the RCH II strategy. It focusses on preventive, promotive and
curative aspects of the programme. The objective is to implement IMNCI package at the level of
household, and through ANMs at sub-centre level; through medical officers, nurse and LHVs at
PHCs level. The major highlights of the Indian adaptation are :

 Inclusion of 0-7 days age in the programme;

 Incorporating national guidelines on malaria, anaemia, vitamin-A supplementation and

immunization schedule;

 Training of the health personnel begins with sick young infants upto 2 months;

 Proportion of training time devoted to sick young infant and sick child is almost equal;
and is skill based.

Rashtriya Bal Swasthya Karyakram (RBSK)

26
RBSK is a new initiative launched in February 2013. It includes provision for Child Health
Screening and Early Intervention Services through early detection and management of 4 Ds,
prevalent in children. These are defects at birth, diseases in children, deficiency conditions and
development delays including disabilities. An estimated 27 crore children in the age group of 0-
18 years are expected to be covered across the country in a phased manner. Child Health
Screening and Early Intervention Services under NRHM envisage to cover 30 identified health
conditions for early detection, free treatment and management. Based on the high prevalence of
diseases like hypothyroidism, sickle cell anaemia and beta thalassaemia in certain geographical
pockets of some states/UTs, and availability of testing and specialized support facilities, these
states and UTs may incorporate them as part of this initiative.
Programme Implementation
For newborn :
Facility based newborn screening at public health facilities, by existing health manpower.
Community based newborn screening at home through ASHAs for newborn till 6 weeks of age
during home visits.
For children 6 weeks to 6 years :
Anganwadi center based screening by. Dedicated Mobile Health Teams.
For children 6 years to 18 years :
Government and Government aided school based screening by dedicated Mobile Health Teams.
The quality indicators used to monitor and evaluate RCH
programme through monthly reports are :
1. Number of antenatal cases registered - total and at less than 12 weeks;
2. Number of pregnant women who had 3 antenatal check-ups;
3. Number of high-risk pregnant women referred;
4. Number of pregnant women who had two doses of tetanus toxoid injection;
5. Number of pregnant women under prophylaxis and treatment for anaemia;
6. Number of deliveries by trained and untrained birth attendant;
7. Number of cases with complications referred to PHC/ FRU;
8. Number of new born with birth weight recorded;
9. Number of women given 3 post natal check-ups;
10. Number of RTI/STI cases detected, treated and referred;

27
 11. Number of children fully immunized;
12. Number of adverse reactions reported after immunization;
13. Number of cases of ARI and diarrhoea under 5 years treated, referred PHC/FRU and
deaths
14. Number of cases motivated and followed up for contraception.
REPRODUCTIVE MATERNAL. NEWBORN CHILD AND ADOLESCENT HEALTH
{RMNCH+A) STRATEGY. 2013
In June 2012, the Government of India, Ethiopia, USA and the UNICEF convened the "Global
Child Survival Call to Action : A Promise to Keep" summit in Washington, DC to energize the
global fight to end preventable child deaths through targeted interventions in effective, life-
saving interventions for children. More than 80 countries gathered at the Call to Action to pledge
to reduce child mortality to 20 child deaths per 1000 live births in every country by 2035. Eight
months after the event, in February 2013, the Government of India held its own historic Summit
on the Call to Action for .Child Survival, where it launched "A Strategic Approach to
Reproductive, Maternal, Newborn, Child, and Adolescent Health (RMNCH+A) in India." Since
that time, RMNCH +A has become the heart of the Government of India's flagship public health
programme, the National Health Mission .With support from USAID and its Maternal Child
Health Integrated Programme (MCHIP), as well as from UNICEF, UNFPA, NIPI and other
development partners, the Government of India has taken important steps to introduce and
support RMNCH+A implementation. This approach is likely to succeed given that India already
has a community based programme with presence of 8. 7 lakh ASHA workers, as well as the
three tiered health system in place. These provide a strong platform for delivery of services. This
integrated strategy can potentially promote greater effeciency while reducing duplication of
resources and efforts in the ongoing programme . The RMNCH+A strategy is based on provision
of comprehensive care through the five pillars, or thematic areas, of reproductive, maternal,
neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care,
entitlement, and accountability. The "plus" within the strategy focusses on : Including
adolescence for the first time as a distinct life stage; Linking maternal and child health to
reproductive health, family planning, adolescent health, HIV, gender, preconception and prenatal
diagnostic techniques; Linking home and community-based services to facilitybased care; and
Ensuring linkages, referrals, and counter-referrals between and among health facilities at primary

28
(primary health centre), secondary (community health centre), and tertiary levels (district
hospital). Guidelines and tools were developed and policies were adjusted.
High-Priority Districts: The RMNCH +A strategy addresses India's inter-state and inter-district
variations. The districts with relatively weak performance against RMNCH+A indicators were
identified. Uniform and clearly defined criteria were used to identify 184 high-priority districts
across all 29 states. The RMNCH+A approach is a conscious articulation of the GOI's
commitment to tailoring programmes to meet the needs of previously underserved groups,
including adolescents, urban poor, and tribal populations.
Management tools and job aids: The RMNCH+A 5x5 matrix identifies five high-impact
interventions across each of the five thematic areas, five cross-cutting and health systems
strengthening interventions, and, the minimum essential commodities across each of the thematic
areas.
Goals and Targets

Taking into account the progress made so far in maternal and child health, it is pertinent to
establish the goals and targets for the implementation phase 2012-2017, after. considering the
main reasons for mortality and interventions proven to have an impact on them. The 12th Five
Year Plan has defined the national health outcomes and the three goals that are relevant to
RMNCH +A strategic approach are as follows:

1) Reduction of Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017.
2) Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017.
3) Reduction in Total Fertility Rate (TFR) to 2.1 by 2017.

Adolescent Health Programme

Taking cognisance of the diverse nature of adolescent health needs, a comprehensive adolescent
health strategy has been developed. The priority under adolescent health include nutrition, sexual
and reproductive health, mental health, addressing gender-based violence, noncommunicable
diseases and substance use. The strategy proposes a set of interventions (health promotion,
prevention, diagnosis, treatment and referral) across levels of care. These interventions and
approaches work towards building protective factors that can help adolescents and young people
develop 'resilience' to resist negative behaviours and operate at four major levels: individual,
family, school and community by providing a comprehensive package of information,
commodities and services. The priority interventions are as follows :

 Adolescent nutrition; iron and folic acid supplementation.

 Facility-based adolescent reproductive and sexual health services (ARSH)

29
  Information and counselling on adolescent sexual reproductive health and other health
issues.
 Menstrual hygiene.
 Preventive health check-ups.

Adolescent Reproductive and Sexual Health programme (ARSH)

Adolescent Reproductive and Sexual Health programme (ARSH) focusses on reorganizing the
existing public health system in order to meet service needs of adolescents. Steps help groups to
provide adequate and appropriate information to adolescents in spaces where they normally
congregate.

Weekly Iron and Folic Acid Supplementation (WJFS)

Ministry of Health and Family Welfare has launched the Weekly Iron and Folic Acid
Supplementation (WIFS) Programme to meet the challenge of high prevalence and incidence of
anaemia amongst adolescent girls and boys. The long term goal is to break the intergenerational
cycle of anaemia, the short term benefit is of a nutritionally improved human capital. The
programme, implemented across the country, both in rural and urban areas, will cover 10.25
crore adolescents. The key interventions under this programme are as follows :

 Administration of supervised weekly iron-folic acid supplements of 100 mg elemental

iron and 500 μg folic acid using a fixed day approach.
 Screening of target groups for moderate/severe anaemia and referring these cases to an
appropriate health facility.
 Biannual de-worming (Albendazole 400 mg), six months apart, for control of helminths
infestation.
 Information and counselling for improving dietary intake and for taking actions for
prevention of intestinal worm infestation.

Menstrual Hygiene Scheme

The Ministry of Health and Family Welfare has launched scheme for promotion of menstrual
hygiene among adolescent girls in the age group of 10-19 years in rural areas. This programme
aims at ensuring that girls have adequate knowledge and information about menstrual hygiene
and have access to high quality sanitary napkins along with safe disposal mechanisms. Key
activities under the scheme include :

o Community based health education and outreach in the target population to promote
menstrual health;
o Ensuring regular availability of sanitary napkins to the adolescents;
o Sourcing and procurement of sanitary napkins;
o Storage and di.stribution of sanitary napkins to the adolescent girls;

30
 o Training of ASHA and nodal teachers in menstrual health, and
o Safe disposal of sanitary napkins.

Care During Pregnancy And Childbirth

Pregnancy and childbirth are physiological events in the life of a woman. Though most
pregnancies result in normal birth, it is estimated that about 15 per cent may develop
complications, which cannot be predicted. Most of these complications can be averted by
preventive care, skilled care at birth, early detection of risk, appropriate and timely management
of obstetric complications and postnatal care. The delivery of services during pregnancy and
childbirth requires a strong element of continuum of care from community to facility level and
vice versa. While the antenatal package, counselling and preparation for newborn care, breast-
feeding, birth and emergency preparedness will mainly be delivered through community
outreach; skilled birth attendance are to be provided at health facilities, primarily 24x7 PHC and
FRU. These facilities are most likely to be the one that have been designated as "delivery points''
and therefore have provision for full complement of RMNCH services. Following discharge
from the health facilities, mothers and newborns will be provided postnatal care through home
visits. Most of these services are already in place.

The priority interventions are as follows

 Delivery of antenatal care package and tracking of high-risk pregnancies.

 Skilled obstetric care.
 Immediate essential newborn care and resuscitation.
 Emergency obstetric and newborn care.
 Postpartum care for mother and newborn.
 Postpartum IUCD and sterilization.
 Implementation of PC & PNDT Act.

Newborn And Child Care

The interventions in this phase of life mainly focus on children under 5 years of age. Given
below are the priority child health interventions that are already in place under NRHM. Priority
Interventions

 Home-based newborn care and prompt referral.

 Facility-based care of the sick newborn.
 Integrated management of common childhood illnesses (diarrhoea, pneumonia and
malaria).
 Child nutrition and essential micronutrients supplementation.
 Immunization
 Early detection and management of defects at birth, deficiencies, diseases and disability
in children 0-18 years of age (Rashtriya Bal Swasthya Karyakram).

31
Care Through The Reproductive Years

Reproductive health needs to exist across the reproductive years and therefore access to these
services is required in various life stages starting from the adolescence phase. Reproductive
health services include the provision for contraceptives, access to comprehensive and safe
abortion services, diagnosis and management of sexually transmitted infections, including HIV.
A new strategic direction has been developed for the family planning programme, wherein it has
been repositioned to not only achieve population stabilisation but also to reduce maternal
mortality as also infant and child mortality. A target-free approach based on unmet needs
forcontraception; equal emphasis on spacing and limiting methods; and promoting 'children by
choice' in the context of reproductive health are the key approaches to be adopted for the
promotion of family planning and improving reproductive health. These services will be
delivered at home, through community outreach and at all levels of health facilities and include
adolescents and adults in the reproductive age group.

Priority interventions

Community-based promotion and delivery of contraceptives.

Promotion of spacing methods (interval IUCD).
Sterilization services (vasectomies and tubectomies).
Comprehensive abortion care (includes MTP Act).
Prevention and management of sexually transmitted and reproductive infections
(STI/RTI).

Delivery Points
The provision of services for delivery care in a health facility generally serves as an important
indicator to assess whether the facility is optimally functional or not. The concept of 'delivery
point' emerges from this presumption. Among the health facilities designated as Ll, L2 and L3,
there are some facilities which are conducting deliveries above a minimum bench mark
(minimum 3 normal deliveries per month at Ll; minimum 10 deliveries per month, including
management of complications, at L2; minimum 20-50 deliveries per month including C-section
at L3). These are designated as delivery points. According to the government mandate, these
facilities should be the first to be strengthened for providing comprehensive RMNCH Services.
This should be supported by a 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 should

32
be to establish and operationalize Basic Emergency Obstetric Care and Comprehensive
Emergency Obstetric Care Centres as per the expected delivery load in the state and district.
Maternal and Child Health (.MCH) Wing
Most health facilities, especially those at secondary and tertiary level are having high case load
of pregnant women and newborn due to increase in institutional deliveries following launch of
JSY and JSSK. Therefore, it has been decided that dedicated Maternal and Child Health
Wingswill be established in high case load facilities with adequate prov1s1on of beds. The new
MCH wings will be comprehensive units (30/50/100 bedded) with antenatal waiting rooms,
labour wing, essential newborn care room, SNCU, operation theatre, blood storage units and a
postnatal ward and an academic wing. This will ensure provision of emergency maternal and
newborn care services as well as 48 hours stay, i.e., quality postnatal care to mothers and
newborns.
INDIA NEWBORN ACTION PLAN (INAP)

In the past two decades, there has been remarkable progress in the survival of mother and
children beyond the newborn period. Presently, the newborn health has captured the attention of
the policy makers and two important milestones in this direction have been the National · Rural
Health Mission and the Reproductive, Maternal, Newborn, Child and Adolescent Health Strategy
(RMNCH+A Strategy), NRHM has provided unprecedented attention and resources for newborn
health. By adopting RMNCH+A strategy in 2013, the country observed a paradigm shift in its
approach towards health care. Newborn health occupies centre stage in the overall strategy as all
the inter-linkages between various components have the greatest impact on the mortality and
morbidity rates of the newborn. In India, Newborn Action Plan (INAP) developed in response to
the global Every Newborn Action Plan (ENAP), was launched in June 2014. The plan outlines a
targeted strategy for accelerating the reduction of preventable newborn deaths and stillbirths in
the country. INAP defines the latest evidence on effective interventions which will not only help
in reducing the burden of stillbirths and neonatal mortality, but also maternal deaths. The goal is
to attain "Single Digit Neonatal Mortality rate by 2030" and Single Digit Stillbirth rate by 2030.
The INAP will be implemented within the existing RMNCH+A framework, and guided by the
principles of integration, equity, gender, quality of care, convergence, accountability and
partnerships. Its strength is built on its six pillars of intervention packages impacting stillbirths
and newborn health, which includes :

33
  Pre-conceptionand antenatal care
 Care during labour and Childbirth
 Immediate newborn care
 Care of the healthy newborn
 Care of small and sick newborn;
 Care beyond newborn survival.

For effective implementation, a systematic plan of monitoring and evaluation has been
developed with a list of dashboard indicators .

Strategic Intervention Packages based on the six packages described below : The
interventions are grouped in six packages, corresponding to the various life stages of the
newborn. It is estimated that high coverage of available intervention packages can prevent almost
three-quarters of the newborn deaths, one-third of stillbirths and half of the maternal deaths by
2025. The interventions have been categorized as :

Essential , to be implemented universally;

Situational , implementation dependent on epidemiological context;

Advanced , implementation based on health system capacity of the state/district.

The states are urged to develop their own action plans

Pre-conception and antenatal care

Care during labour and childbirth
Immediate newborn care
Care of healthy newborn
Care of small and sick newborn
Care beyond newborn survival

Monitoring and Evaluation

A comphrehensive assessment of targets would be done in 2020, which will help plan course
corrections, if any, in on-going interventions. Further, from the year 2020, the milestones will be
reviewed every five years .

34
SUMMARY
 Health & Family Welfare Programme started in India in 1951, with the National Family
Planning Programme. The Family Planning Programme focused mainly on terminal methods
with a view to control over population growth. As a result, it received set back owing to rigid
implementation of target-based approach. The experiences gained throughout the country
revealed that improvement of the health of women in the reproductive age group and children
(up to 5 years) is of crucial importance to reduce the problem of population growth. This
realization led to change in the approach from Family Planning to Family Welfare. Since the 7th
Plan implemented during 1984 – 89, the Family Welfare programme have evolved on the health
needs of mothers and children, as well as on providing contraceptives and spacing services to the
targeted group. The main objective of Family Welfare programme has been to stabilize the
population at level of the need of the country’s development.In 1997, the Government of India
followed up the International recommendation on Reproductive and Child Health (RCH) as a
National Programme. RCH programme integrates all the related programmes of the eight plan
and it aims to bring all RCH services easily available for the community. RCH I has technically
ended on 31st March 2004. The Government of India has however extended one year Interim
period for preparation of project implementation plan (PIP) for RCH II. Since there have been
improvements in the areas of services provided to some extent during RCH I, the Government of
India decided to continue RCH phase II so that the targeted group may get better health at
maximum level.And in 2013 government of India added RMNCH+A programme by providing
comprehensive care through the five pillars, or thematic areas, of reproductive, maternal,
neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care,
entitlement, and accountability.
CONCLUSION
Reproductive and child health approach has been defined as "people have the ability to
reproduce and regulate their fertility, women are able to go through pregnancy and child birth
safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well
being, and couples are able to have sexual relations, free of fear of pregnancy and of contracting
disease. The concept is in keeping with the evolution of an integrated approach to the
programme aimed at improving the health status of young women and young children which has
been going on in the country named as RCH programmes.

35
JOURNEL ABSTRACT
An overview of multicentric training workshops for public health professionals on reproductive
and child health programme in India.(PMID:12653007)
Biswas R , Ray SK , Dobe M , Dasgupta S , Mandal A  Indian Journal of Public Health [01 Jul
2002, 46(3):78-85]Type: Research Support, Non-U.S. Gov't, Evaluation Studies, Journal Article
Abstract
The major emphasis of Reproductive and Child Health (RCH) programme in India is delivery of
client-oriented, demand driven and broader ranges of high quality, safe and effective services for
children, adolescents, mothers and reproductive age group population at large. Increased client
satisfaction is considered as main determinant for improved acceptance of the services. Thus,
well trained and motivated health personnel are necessary to deal with highly sensitive, personal
health issues of the clients, like contraception, abortion, infertility services etc. The Indian Public
Health Association organized total 10 workshops in several places of India (A total 322
members, composed of Medical Administrators (54.7%), Faculty members of Medical Colleges
(24.5%), Sociologist and Nutritionists (13.9%) and also public health personnel (6.9%)
participated in the workshop). Learning objectives and lesson plans etc. were formulated.
Accordingly the contents were incorporated in a module, validated and pretested. The training
sessions were conducted by briefing, discussion, group exercise and VIPP method and were
evaluated by semi structured. The pre/post assessment schedule and scored scale of feedback
from participantsAE were used for evaluation. The pre-post assessment scores revealed wide
variations of mean score among the participants of several places. Significant post workshop
improvement of knowledge was quite evident, with few exceptions. The group variants of pre
and post score of results was considered to be due to heterogeneous groups of participants.
Review of objectivity and quality of the questionnaire were felt as necessary.
ASSIGNMENT
Findout current statistics data regarding RCH programmes.
AV AIDS
Black board
Powerpoint presentations
Chart
Flash card

36
REFERANCE
1. Park.k.parks textbook of preventive & social medicine.25th edition.banarasidas bhanot
publisher.jabalpur;2019.480-499
2. Swarnkar k.community health nursing.2nd edition.NR brothers.indore;2008.639-642
3. Jacob a .a comprehensive textbookof midwifery.2nd edition.jaypee brothers
medicalpublishers. New delhi;2008.629-6
4. Kumarai n .a textbook of community health nursing.2nd edition. S.vikas&company
.jalandhar;2014.773-785
5. Biswas R , Ray SK , Dobe M , Dasgupta S , Mandal A. An overview of multicentric
training workshops for public health professionals on reproductive and child health
programme in India. Indian Journal of Public Health [01 Jul 2002, 46(3):78-85]
6. Nayak, Malathi & Bengre, Ansuya. (2010). A study on the awareness of utilization of
reproductive and child health (RCH) services in the selected villages of Udupi District,
Karnataka. International journal of nursing education. 2.

37