INDEX

SL No. CONTENTS PAGE No.

1 POPULATION DYNAMICS 02-04
2 VITAL STATISTICS 05-13
3 FAMILY PLANNING 14-22
4 RECENT ADVANCEMENT IN 22-24
CONTRACEPTIVE TECHNOLOGY
5 ROLE OF NURSES IN FAMILY 25-41
WELFARE PROGRAMMES IN ALL
SETTINGS
6 ROLE OF INDEPENDENT NURSE 42-45
MIDWIFERY PRACTITIONER
7 CONCLUSION 46
8 BIBLIOGRAPHY 47

POPULATION DYNAMICS
POPULATION:
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 • All the individuals of a species that live together in an area.

DEMOGRAPHY:
• The statistical study of populations, allows predictions to be made about how a
population will change.

POPULATION DYNAMICS
Three Key Features of Populations
• Size
• Density
• Dispersion

THREE KEY FEATURES OF POPULATIONS

I. Size – number of individuals in an area
Growth Rate:
 Birth Rate (natality) - Death Rate (mortality)
 How many individuals are born vs. how many die
 Birth rate (b) − death rate (d) = rate of natural increase (r)

II. Density: measurement of population per unit area or unit volume

Population Density = number of individuals ÷ unit of space
Factors that Affects Density
1. Immigration: movement of individuals into a population
2. Emigration: movement of individuals out of a population
3. Density-dependent factors: Biotic factors in the environment that have an increasing
effect as population size increases (disease, competition, parasites)
4. Density-independent factors: Abiotic factors in the environment that affect populations
regardless of their density (temperature, weather).

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 III. Dispersion—describes the spacing of organisms relative to each other
• Clumped
• Uniform
• Random

Carrying Capacity (k):

 The maximum population size that can be supported by the available resources.
 There can only be as many organisms as the environmental resources can support.

Factors Limiting Growth Rate

Declining birth rate or increasing death rate are caused by several factors including:
• Limited food supply
• The buildup of toxic wastes
• Increased disease
• Predation

Reproductive Strategies
R Strategists
 Short life span
 Small body size
 Reproduce quickly
 Have many young
 Little parental care
 Ex: cockroaches, weeds, bacteria
K Strategists
 Long life span
 Large body size
 Reproduce slowly
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  Have few young
 Provides parental care
 Ex: humans, elephants

Age Distribution
 Distribution of males and females in each age group of a population
 Used to predict future population growth

Human Population Growth

J curve growth
• Grows at a rate of about 80 million yearly
r =1.3%
• Why doesn’t environmental resistance take effect?
• Altering their environment
• Technological advances
• The cultural revolution
• The agricultural revolution
• The industrial-medical revolution
• Doubled three times in the last three centuries
• About 6.1 billion and may reach 9.3 billion by the year 2050
• Improved health and technology have lowered death rates

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FAMILY PLANNING
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Definition of Family Planning
Family planning is a way of thinking and living that it is adopted voluntary upon the
basis of knowledge, attitude and responsible decision by person and couple in order to provide
the health and welfare of the family group and thus contribute effectively to the social
development of a country-WHO

Objectives of Family Planning:-

 To avoid unwanted births.
 To bring out wanted births.
 To regulate the interval between pregnancies
 To control the time at which birth occurs in relation to the age of parents.
 To determine the number of children in the family.

Services That Make This Practice Possible Are:-

 Education and counselling on family planning.
 The provision of contraception.
 The management of infertility.
 Education about sex and parenthood.
 Organizationally related activities such as genetic and marriage counselling, screening for
abnormalities and adoption services.

Small Family Norm And Its Importance

All the efforts are being made through mass communication that the concept is accepted ,
adopted into the lifestyle of the people. The norm in relation into family size,implies a pattern
which sets the limits of any community’s fertility behaviour.The size of family affects the
quality of life of human beings.

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Family size affects the family in following spheres of life:-
 Basic human needs
 Income and growth of economy and savings.
 Food and nutrition ,quality and quantity.
 Use of land and urban public system.
 Health especially that of mothers of child.

ADVANTAGES OF FAMILY PLANNING

 TO MOTHER:
 In a small planned family,a mother can maintainher health by restricting the no. of the
children and spacing herpregnancy.
 It creates loss of fear about unwanted pregnancy.
 Mother will have been strain and worry due to limited number of children.
 Mother will have more to give proper attention and love her children.
 Mother will have more time to participate in other fruitful attributes like education,
vocation training, community project etc.
 Mother can await better job opportunities in small family.
 Mother can save child’s health, low chance of foetal death, birth defects, mortality
during infancy and childhood.

 TO CHILD:
 Child will have a good environment for his proper psychological growth and
development.
 Child get proper nutrition, education, parental care and love.
 Child can provide sound economic base for family.

 TO FATHER:
 Father can provide children with better education ,comfort, food, clothing, recreation.

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  He will be more relaxed and enjoy good health.
 He will have improved living standard, better health.

 TO COMMUNITY:
 Small family leads to conservation of natural resources and savings.
 Small family norms helps the nation to have enough school, hospital and other basis
services.
 Small family norm yields more employment.
 Small planned families would gradually bring happiness,harmony and prosperity.

CONTRACEPTIVE METHODS:

Contraceptive methods are preventive methods to help women avoid unwanted pregnancies.
They include all temporary and permanent methods to prevent pregnancy resulting from coitus,

Criteria For Ideal Contraceptive

 It should be safe for use ,means free from any kind of side effects.
 It should be reliable.
 It should be easy to administer and convenient.
 It should be cost effective.
 It should be culturally feasible and acceptable.

Methods Of Contraceptives:-

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 CONTRACEPTIVE METHODS

SPACING METHODS TERMINAL METHODS

POST- INTRA
BARRI CONC - HORM
MISCE
ER EPTIO UTERI ONAL MALE FEMALE
LLAN
METH NAL NE METH STERLIZATION STERLIZATION
EOUS
ODS METH DEVIC ODS
ODS ES

I. SPACING METHODS:
o Help in prevention of pregnancy as long as they are used.
o Help in timing and spacing of pregnancy preventing unwanted children.
o These methods are temporary methods.

A. BARRIER METHODS:
Barrier methods are those methods which prevent meeting of sperms with the ovum.
There are three types of barrier method:-

1. Physical Barrier method:-

 Condom(nirodh)
It is a thin rubber sheath which is used by men.it is rolled over the erect penis before
having sex. This rubber sheath prevents the entry of semen into the vagina.
 Female condom
It is a pouch made of polyurethane, which lines the vagina. An internal ring in the close
end of the pouch covers the cervix and an external ring remains outside the vagina.
 Diaphragm
The diaphragm is used by women in her vagina to form a barrier in front of the cervix.
The diaphragm is dome shape and is like a shallow cap. It is made of soft synthetic
rubber or plastic with a stiff but flexible rim around the edge.

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  Vaginal sponge
It is a small polyurethane foam sponge, diffused with spermicide. The sponge is shaped
in a way that it can be fitted on the cervix and has a loop on its outer surface which can
be used to pull out the sponge after use.
-should be inserted before the coitus
-provides protection for 24 hours.

2. Chemical methods:
These methods usually kills the sperms and the chemical contraceptives help in
preventing the pregnancy. They comprise four categories:-
 Foams
 Creams
 Suppositories
 Soluble films

3. Combined methods:

B. INTRA-UTERINE DEVICES:
These are the devices which are placed into the uterine cavity. Earlier these devices were
made up of silk worm gut, silk and gold.
There are three different type of IUD’s:-
 First generation IUD’s
These devices comprise the inert or non-medicated devices, usually made of polythene,
or other polymers.eg. Lippes loop-it contains a small amount of barium sulphate to allow
x-ray observation.
 Second generation IUD’s
These are also made of polythene but copper is added into these. The copper enhances the
contraceptive effect. Variety of copper-T devices are:-
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 -copper-7 and copper-T200
-Variants of T devices: TCu:220C:and TCu:380A
-Multiload devices:ML-Cu:250,ML-Cu:375
-nova T:TCu-380
 Third generation IUD’s
These contains hormones which is released slowly in the uterus. The hormone affects the
lining of uterus and cervical mucus. It may affect the sperm.eg- progestasert and LNG-
20(Mirena).

C. HORMONAL METHODS:
These are found to be the most effective method to prevent unwanted pregnancies. These
are classified as below:-
 Oral pills:
 Combined pill: It contains oestrogen and progesterone. The pill is given orally for 21
consecutive days beginning on the 5 th day of menstrual cycle followed by a break of 7
days during which period mensturationoccurs.eg:- MALA-N and MALA-D.
 Progesterone only pill: This pill commonly referred as minipill or micropill. It contains
only progesterone, which is given in small doses through-out the cycle.eg:-
levonorgestrel.
 Post-coital pill: It recommended within 72 hours of an unprotected intercourse.
 Once a month(long-acting pill):Once-a-month oral pill in which quinestrol, a long acting
oestrogen is given in combination with short acting progesterone.
 Male pill: An ideal male contraceptive pill would decrease sperm count while leaving
testosterone at normal levels. A male pill is made up of gossypol- a derivative of cotton
seed oil.
 Depot formulations:
They are highly effective, reversible, long-acting and oestrogen- free for spacing
pregnancies in which a single administration is sufficient for several months or years.

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  Injectables
There are two types of injectable contraceptives:-
 Progesterone-only injectables i.e DMPA,NET-EN,DMPA-SC.
 Combined injectables contraceptives:-these contain progesterone and an oestrogen.
They are given at monthly intervals plus or minus 3 days.
 Subdermal implants: Nor- plant is a highly effective, reversible, oestrogen free, long-
acting contraceptive.it is implanted sub dermally.
 Vaginal rings: Vaginal rings containing levonorgestrel have been found to be effective.
The hormone is slowly absorbed through the vaginal mucosa. The ring is worn in the
vagina for 3 weeks of the cycle and removed for the fourth.

D. POST-CONCEPTIONAL METHODS
Post conceptional method is advocated as an emergency method.eg. after unprotected
intercourse, rape or contraceptive failure. Two methods are available:-
 Hormonal- in this progesterone 0.75mg is taken as soon as possible or within 72 hours of
unprotected intercourse and 2nd dose is taken 12 hours after the intake of first dose or two
tablets(1.5mg) are taken together as soon as possible or within 72 hours.
 IUD-The the simplest technique is to insert IUD within 5 days of unprotected sex.

E. MISCELLANEOUS
 Abstinence(withdrawl)- It is an ancient method of contraception. The male withdraws
just before ejaculation and thereby prevents deposition of semen in the vagina.
The risk of pregnancy is very high because small amounts of pre-ejaculatory fluid
containing sperms ooze out during intercourse.
 Rhythm method- A week before and a week after the menses is considered as the safe
period. During this period the women is not fertile because she can not ovulate. For eg. If
the day of menstruation for a women is Monday, the next Monday will be her first risky

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 day. The period between the first risky Monday and last risky Monday will be the unsafe
period.
 Breast feeding- Breast feeding has a natural contraceptive effect. The mother should be
encouraged to breast feed their babies for more than one year. This will help in spacing
the birth of their children more widely.

II. TERMINAL METHODS

A. MALE STERILIZATION

Male sterilization or vasectomy being a comparatively simple operation under strict aseptic
technique. It involve cutting and tying off the vas deferens(sperm tubes) on each side.

No scalpel vasectomy:-it is performed under local anaesthesia. The vas is grasped with a
specially designed forceps. Stretched skin over the vas is punctured with the sharp pointed end
of a forceps instead of using a scalpel. No skin suturing is needed

B. FEMALE STERILIZATION
Female sterilization can be done as an interval procedure or at the time of abortion.
It involves cutting and tying off the fallopian tube:
There are three main methods of female sterilization:-
 Traditional tubectomy:- This is an abdominal operation in which small piece of each
fallopian tube is removed and ligated.
 Mini-lap operation:- It is a modification of the traditional laparotomy tubectomy. It
requires a small suprapubic incision of 2.5 to 3cm just above the pubic hair. The tubes
are cut ends are blocked then the incision is closed.
 Laparoscope:- With the laparoscope the tubes are identified then the fallope rings are
applied to occlude the tubes.

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 RECENT ADVANCEMENT IN CONTRACEPTIVE
TECHNOLOGY
INTRODUCTION:
Contraception means preventing the union of the sperm and ovum; suppressing
ovulation; or interfering with the implantation of fertilized ovum in the uterus.
The term contraception includes all measures temporary or permanent, designed to prevent
pregnancy due to the coital act.
Ideal contraceptive should fulfill the following criteria
 Widely acceptable
 Inexpensive
 Simple to use
 Safe
 Highly effective
 Requiring minimal motivation, maintenance &supervision.
The last few years have witnessed a contraceptive revolution; i.e. man is trying to interfere with
the ovulation cycle.
The failure rate of any contraceptive is calculated in terms of pregnancy rate per hundred
women years (H.W.Y)o use. It is calculated according to formula (pearl index)
Pregnancy failure rate/H.W.Y = No. of accidental pregnancies x 1200
No. of patients observed months’ of use
Where 1200=no. of months in 100 years.
The present approach in family planning programme is to provide a cafeteria choice” that is to
offer all methods from which an individual can choose according to his needs and wishes and to
promote family planning as a way of life.
The contraceptive prevalence rate for modern methods of contraception in India is 42.8%
(48%for all methods), with female sterilization ‘accounting for 34.2%, pill use for 2.1%, IUD
use for 1.6% and condom use for 3.1%[2].Male sterilization accounts for 1.9%. China has a
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modem contraceptive user ate of 83.3% with IUD use accounting for 36.4%and female
sterilization for 33.5%. Despite the rise in use of family planning as evidenced in surveys, One-
fourth of births worldwide are unplanned. Over the past 30 years, there have been significant
advances in the development of new contraceptive technologies, including transition from high
dose to low dose combined oral contraceptives and from inert to copper and levonorgestrel
releasing intrauterine devices (IUDs). In addition, combined injectable contraceptives, a
combined hormonal patch and ring and progestogen-only injectable and implants have been
introduced in the last four years.
This review will focus on the non-daily hormonal contraceptives introduced in the last few
years. Along with new evidence-based recommendations on other commonly used methods of
contraception.

Sino- implant II: A contraceptive implant manufactured by Shanhai Dahua Pharmaceuticals in

china. According to Ruth Merkatz of population council, the sino- implant is available at more
than 60% less than the price of the other implants available on the market. It is registered in
china, Indonesia, serriaand Kenya. More than 7 million implants have been distributed, and
11published clinical trials show that this new device is safe and effective. The device will
probably cost about $6 to $7. It is not currently seeking U.S approval but is undergoing the
approval process in several other markets.

SILCS Diaphragm: A one size, easy to use, over the counter diaphragm produced by GHC
member PATH. This new product eliminates the need for a fitting exam, and women can
comfortably insert the device themselves at home with the assistance of written instructions. An
effectiveness and safety study of new diaphragm began in 2008 and is near completion in six
sites across United States. Evidence collected suggests that the majority of women can insert
this device safely and position it correctly, suggesting that it will meet the criteria for OTC
marketing.

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NES/EE contraceptive vaginal ring (CVR): a user-controlled CVR produced by the
population council. Unlike other CVRs that can only be used for a month. This new CVR can
be used for upto 13 cycles or one year, reducing costs and increasing user convenience. The
NES/EE CVR is currently undergoing phase III clinical trials to determine if it is safe and
effective, and to assess cycle control, return to fertility and side effects. Preliminary findings
suggest this new device is highly effective in preventing pregnancy and has a safety profile that
is similar to other contraceptives. Population council aims for this contraceptive to hit markets
in 2011.

Depo-subQ Provera 104 in the uniject Device: a technology that packages a familier
injectable contraceptive into a one- use, prefilled injection system. The uniject device is a single
prefilled delivery service with subcutaneous needle.” It is basically like a pre-filled syringe that
is only good for one use. The proper amount of Depo- subQ Provera 104(similar to currently
used Depo but reformatted to fit the new device) is already loaded into the uniject device, and
can be injected under the skin rather than the muscle. This new contraceptive technology will
help to reduce waste (packaging) and improve safety (one- use needle), and is easier to deliver
by nature of the pre-loaded uniject device.

Many of these new contraceptive devices are most cost efficient and easier to use than the
other devices on the market. The SILCS diaphragm and the CVR are both user- controlled
contraceptives that can be easily inserted by women and can be used again and again for many
months. In addition many of these new contraceptives could be easily distributed or delivered
by community health workers.
The new packaging of Depo e.g. makes it feasible for a community health worker to
administer it directly. More information is needed on the removal of the implant, as some
women may not come back at the appropriate time after insertion. In addition, the instructions
to use the diaphragm are only written in English, which might be problematic for non- English
speakers or illiterate populations.

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 Collectively these new contraceptives represent a promising new variety of methods,
both short- term to long – lasting, to help meet the needs of women during different stages of
their reproductive lifespan.
ROLE OF NURSES IN FAMILY WELFARE PROGRAMMES IN
ALL SETTINGS
INTRODUCTION:
The national family welfare program was launched in 1952 as National Family Planning
program. India was the first one to do so. It is 100% centrally sponsored program. The ministry
of Health and Family welfare was responsible for this program. In 1977 the Government re-
designated the National Family Planning Program as National Family Welfare Program. The
concept of ‘welfare is related with the quality of life’ of the family.

HISTORICAL BACKGROUND:
 During the1950 Government of India introduced Maternal and Child health (MCH)
services as basic health services in Primary Health Centers because of their increased
vulnerability and morbidity and mortality.
 During 1952, National Family Planning Program was launched to control population
growth in India. The services were target oriented resulting in burden on health workers,
which ultimately affected the quality of work.
 During 1972, abortion was legalized due to increased maternal deaths following illegal
abortions.
 During 1975, emergency was declared in India by the Government.
 During 1976, the disastrous forcible sterilization campaign led to the defeat of congress
Government and the new Janatha Government during 1977, rule out compulsion and
coercion of Family Planning Services and renamed the program as ‘Family Welfare
Program’ by providing a package of services to the mothers and children in integrated
manner, comprising maternity services ( antenatal, intra natal and postnatal care),

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 nutritional services (supplementary nutrition), immunization services and family planning
services, for the welfare of the entire family.
 During 1978, Government of India upgraded the immunization services and launched
WHO recommended expanded program of Immunization (EPI)
 During 1978-79, meanwhile Government of India became signatory to Alma-Ata
Declaration of achieving the Global Social Target ‘Health For All by 2000 AD’
 During 1985, Expanded program of immunization was renamed ‘Universal
Immunization Program (UIP)’ by concentrating the services to infants and expected
mothers.
 During 1992, to achieve the social target and to improve the quality of services to
mothers and children, the services were integrated into a single composite program called
the ‘Child Survival and Safe Motherhood Program (CSSM)’, a time bound and target
oriented National Program.
 The time bound was 2000 AD and the target population was all mothers and under five
children.

I. REPRODUCTIVE AND CHILD HEALTH PROGRAM (RCH)

It was formally launched by Government of India on 15th October, 1997 as per

recommendation of International Conference on Population and development held in Cairo in
1994.
RCH is defined as “a state in which people have the ability to reproduce and regulate
their fertility and are able to go through the pregnancy and child birth, the outcome of
pregnancy in successful in terms of maternal and infant survival and wellbeing, and couples are
able to have sexual relation free of the fear of pregnancy and of contracting diseases”.
Objectives:
 To improve the health of the mothers and children to ensure safe motherhood and child
survival.
 The intermediate to objective is to reduce IMR and MMR.
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  The ultimate objective is population stabilization, through responsible reproductive
behavior.
Intervention:
 Prevention and management of un-wanted pregnancies.
 Maternal care (safe motherhood)
 Child survival
 Prevention and management of RTIs/STD
 Prevention of HIV/AIDS
Components of RCH:
Main components- Family planning, child survival and safe motherhood program
(CSSM), prevention and management of RTIs, STD and AIDS, client approach to health care.
Other activities:
 Providing counseling, formation and communication services on health, sexuality
and gender difference.
 Referral services for all above intervention
 Growth monitoring, nutrition education, reproductive health services for
adolescents etc.
RCH Package for various services:
1. For maternal services- Obstetric care, infection control and nutrition promotion.
2. For child services- The essential care of the newborn, including care of the at risk
newborn by prompt referral service. Infection control measures and nutrition promotion.
3. Reproductive health- fertility control, MTP services (for prevention and management of
un-wanted pregnancies), adolescent health, HIV/AIDS
RCH Program Phase-I
Under RCH program phase I, various provisions were made to improve the status of
maternal and child health. These include:
 Provision of essential and emergency obstetric care.
 Provision of equipment and drug kits to selected PHCs and selected FRUs in all districts.
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  Provision for additional ANM, staff nurse and laboratory technicians for selected
districts.
 Provision for 24 hours delivery services at PHCs and CHCs
 Referral transport in case of obstetric complication.
 Immunization and oral rehydration therapy.
 Prevention and control of vitamin A deficiency in children.
 Integrated management of childhood illness.
 District surveys for focused intervention to reduce IMR or MMR
 Setting up of blood storage units at FRUs.
 Training of MBBS doctor in anesthetic skill for emergency obstetric care at FRU.
RCH Phase II:
It was started from 1st April 2005 up to 2009. The RCH II vision articulates “improving
access, use and quality of RCH services, especially for the poor and underserved population.
Aims of RCH phase II :
 To reduce IMR, MMR, TFR, and to increase couple protection rate and immunization
coverage specially in rural areas.
 To improve the management performance
 To develop human resources intensively
 To expand RCH services to tribal areas also.
 To monitor and evaluate the services.
 To improve the quality, coverage and effectiveness of the existing family welfare
services and essential RCH services with a special focus on the EAG states.
Components of RCH phase II:
1. Population stabilization:
 By incorporating newer choices of contraceptive methods. Eg. Centchroman
 By increasing trained personnel
 By converging the services at grass root level
 By public private partnership

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  Social marketing of contraceptives to be strengthened.
 Involving panchayti raj institution, urban, local bodies and NGOs
 By increasing incentives
2. Maternal health:
 Essential obstetric care-3 or more checkups, 2 doses of TT, Iron and folic acid
tablets, counseling
 Emergency obstetric care-first referral unit.
3. Newborn care and child health strategies:
 Skilled care at birth
 Strengthen IMNCI services
 Ensuring referral service of sick neonates and utilization of referral funds
 Permitting ANMs to administer selected antibiotics like gentamycin and co-
trimoxasole
 Availability of drugs and supplies
 Promoting breastfeeding practices
 Vitamin A, folic acid, iron supplementation
4. Adolescent health strategies:
 Enroll newly married couples
 Provision of spacing methods
 Routine antenatal care and institutional delivery
 Referral service.
5. Control of RTI/STI:
 HIV/AIDS/STI prevention education and counseling

6. Urban health
7. Tribal health
8. Monitoring and evaluation

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 II. INTEGRATED CHILD DEVELOPMENT SERVICES:
It was launched in October 2nd 1975. It is one of the unique and largest programs for
early childhood development. The main beneficiaries of the program were aimed to be the girl
child up to her adolescence, all children below the age of 6 years, pregnant and lactating
mothers.

Objectives:

 To improve the nutritional and health status of the children in the age group 0-6 years.
 To lay the foundation for proper psychological, physical and social development of the
child.
 To reduce the incidence of mortality, morbidity, malnutrition and school drop-out
 To achieve effective co-ordination of policy and implementation amongst the various
departments to promote child development.
 To enhance the capability of the mother to look after the normal health and nutritional
needs of the child by giving health education to the mother.

Package of services include:

1. Supplementary nutrition
2. Immunization
3. Health check-ups
4. Referral services
5. Pre-school non-formal education
6. Nutrition and health education

Supplementary nutrition and periodic growth monitoring are done regularly through
Anganwadis. Severely malnourished children are given special feeding and medical referral
services. It includes Vitamin A syrup and IFA tablets distribution. Immunization against 6
vaccine preventable diseases are given.

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 Health check ups, weight monitoring immunization, management of malnutrition,
treatment of diarrhea. De- worming and distribution of simple medicines are given to children
below 6 years of age.

Referral servicesanganwadi worker are trained to identify malnutrition, disabilities and

minor ailments and they will refer these cases to PHCs or sub centers.

Pre-school education is given to through anganwadi centers. If focuses on the overall

development of the child. They provide a natural, joyful and stimulating environment for the
children with special emphasis on necessary inputs for optional growth and development.

Nutrition and health education is one of the important work of the anganwadi worker.
This forms part of behavior change communication (BCC) strategy. This has the long term goal
of capacity building of women-especially in the age group of 15-45 years so that they can look
after their own health, nutrition and development needs as well as that of their children and their
families.

ICDS Team comprises of:

 Anganwadi workers, anganwadi helpers

 Supervisors
 Child development project officers
 District program officer
 Medical officers
 Auxiliary nurse midwife
 Accredited social health activist (ASHA)

III. MATERNAL AND CHILD HEALTH SERVICES:

According to WHO 1976, maternal and child health services can be define as
“promoting, preventing, therapeutic or rehabilitation facility or care for the mother and child”
Aims and objectives:
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  Reducing maternal, perinatal, infant and child mortality and morbidity rates
 Child survival
 Promoting reproductive health or safe motherhood
 Ensure birth of a healthy child
 Prevent malnutrition
 Prevent communicable diseases
 Early diagnosis and treatment of health problems
 Health education and family planning services.
Component of MCH:
 Maternal health
 Family planning
 Child health
 School health
 Handicapped children
 Care of the children in special setting such as day care centers.
Package of services:
1. Complete health check-up of child and mother from contraception to birth
2. Studying the health problems of the mothers and children
3. Providing health education to the parents for taking care of children
4. Training to professional and assistant health workers.
Indicators of maternal and child health:
 MMR
 IMR
 Neonatal mortality rate
 Under five mortality rate
 Child survival rate
Maternal and child health services:

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 1. Antenatal care services
2. Intra-natal care services
3. Postnatal care services
4. Under-five child health services
Antenatal services objectives:
 To detect high risk cases and give them special care
 To identify complications and prevent them
 To educate the mother
 To promote, protect and maintain health
Intra-natal services:
 To provide through asepsis
 To prevent injury to baby and mother
 To prevent complication
 To provide care to the baby
Postnatal services:
 To provide care to mother and baby
 To prevent complication
 To provide family planning services, basic education to the mother.
Child health services:
 Decreasing child death and infant mortality
 Complete protection of child
 Nutritious diet to children
 Overall growth of children
 Preserve and promote health of under-five children.

IV. CHILD SURVIVAL AND SAFE MOTHERHOOD:

Aims:

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  To reduce infant mortality
 Provide antenatal care to all women
 Ensure safe delivery services
 Provide basic care to all neonates
 Identify and refer those neonates who are at risk
Later in 1997, RCH included safe motherhood and family welfare as an integrated
approach.

Levels of maternal and child health care services:

Levels of MCH centers have been defined on the basis of MCH services delivery
package. They are as follows
Level I MCH centers (Primary):They include sub-centers and primary health centers
providing skilled birth attendant level delivery care.

Level II MCH centers (secondary): The are the health facilities including the PHCs and
CHCs. They provide nutritional deliveries including management of complicated deliveries not
requiring surgeries. Facilities such as MTP, sterilization and care of sick newborn are also
available here.

Level III MCH centers (Tertiary): Health facilities (CHCs/DHs) providing critical emergency
obstetrical and newborn care (CEmONC) with fully functional operation theatre, blood bank,
sick newborn care etc.

Level I MCH care:

Services available a level I MCH care centers are as follows:
 Antenatal care package: Registration of pregnant woman within 12 weeks, physical
examination, identification of high risk for referral, and provision of iron and folic acid
(IFA) for pregnant and anemic woman.

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  Delivery package: Normal delivery with use of partograph, active management of third
stage of labor (AMTSL), prevention of infection and pre-referral management of
obstetrical emergencies.
 Postnatal care package: Minimum 6 hours post delivery stay in health facility and home
visits for PNC check-up
 Newborn health care package: Newborn resuscitation, warmth, infection prevention,
support for breast feeding initiation, weighing the newborn, care of a low birth weight
newborn, and referral services of sick newborns.
 RTI/STI management
 Counseling and referral services
 Family planning services: Provision of emergency contraceptive pills, counseling and
motivation for small family norms, distribution of OCP, condoms and IUD insertion
follow up care
 “Assured” referrsl system to higher health facility
 Complete immunization
 Counseling for feeding, nutrition, family planning and immunization
 Human resources: Minimum two skilled birth attendants are available

Level II MCH care:

Level II care facilities are those to manage obstetrical emergencies or complications

arising from pregnancy or labor. Services available in level II MCH care centers are as follows.

 Management of all complication encountered by the woman during delivery including

provision of blood transfusion and surgery. Facilities are available for mothers for
episiotomy and suturing, repairing of cervical tears, management of obstetrical
emergencies, assisted vaginal delivery and any surgery that is required before referring
the patient to other health facility.
 Mothers can stay for 48 hour in this facility,stabilize their condition encountered during
delivery and post-delivery complication.
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  Safe abortion services are available for women as per MTP act, with manual vacuum
aspiration up to 7 weeks of pregnancy and referral services, if required
 In case of preterm babies, antenatal corticosteroids are available here and also care of
newborn with low birth weight. Sepsis management and inj.Vitamin K for premature
babies are available and referral services for babies with complications are taken care of.
 Identification and management of RTI/STI is another service provided by this facility
 At this level, family planning services include male sterilization, NSV, tubectomy and
IUD insertion facilities. Referral services with transportation are assured to higher health
facility, if needed.
 Staffing pattern include one or two medical officers and 3-5 nurses or midwives with
SBA training.

Level III MCH care:

With the mother/infant is not able to recover from the treatment given in level II, they are
transferred to level III health facility. Skilled birth attendants, neonatologists/pediatrician,
professional nurses, anesthetists and laboratory and blood transfusion facilities are available
here for 24 hours, 7 days in a week. Services available at level III MCH care centers are as
follows.

 Apart from the facilities for level I and level II MCH care services, level III has blood
storage facilities. This facility manages severe anemia and intra-partum and post-partum
complication including facility for blood transfusion.
 Facilities for patient requiring safe abortion services up to 20 weeks of pregnancy.
 Facilities are available as per the MTP act and it manages all post abortion complication
 In this health facility, a low birth weight baby, and a high risk sick newborns are
managed.
 Mothers with RTI and STI requiring specialized care are managed in level III facility.
 With regard to family planning services, in addition to such services included level I and
II along with management of complication, other family planning services available are

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 male sterilization, NSV, female sterilization, conventional tubectomy, mini lap and
laproscopic sterilization.
 Staffing pattern in level III MCH care includes an obstetrician, anesthetists, pediatrician,
technician/medical officer with skill for blood transfusion support, nine nurses, (available
in 24 hours services)

ORGANIZATION AND ADMINISTRATION OF FAMILY PALNNING:

Family planning program and related activities are managed at various levels-central,
state, district, block village levels- to ensure that they reach to maximum people.

Central level:
The central government controls the planning and financial management of the family
planning programs, the training involved and the evaluation. A population advisory council
headed by the Union Minister of Health and members of parliament and persons related to the
field of population control was set up to 1982. The hierarchy of this council is shown below.
Population council hierarchy

The central Minister of Health and Family Welfare

Secretary of health and Family welfare

Special secretary, department of Family Welfare

Joint Secretaries and Comimissioners

Additional Secretaries

 Policy division
 Aided program division
 Plan budget
 Organized operation media, media communication
 Mass and transport division
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  Supply intelligence

State level:
The centre provides 1005 assistance to the state governments for services and education
for family planning. During the second five-year plan period, Family planning Bureaus were
established in each state, with their capital cities as the head quarters. The state head quarters
was headed by the additional, joint or deputy director of health services. The hierarchy in these
bureaus is shown below.

State Health minister

Health minister

Health Secretary

Director of health services

Additional director- Family Planning

Deputy Director Immunization Deputy Director

(Child health) cold chain (maternal health)
Research
Statistics
Health education
Mass education

District level:
In 1993, District Family Planning Bureau was established under the charge of the District
Family Planning Officers with facilities for publicity services, sterilization, and intra uterine
contraceptive application. The administration at the district level is highlighted below.

38 officer-1
District Family Welfare
 Medical officers-2

Extension educators-2

Block level: Information officer

There is rural family welfare centre with medical officers and supporting staff. Services
like sterilization, IUCD insertion are provided at the PHC’s. Sub centers are the control of
PHCs. Each sub-center has one male and female health worker. They provide motivation for
Statistician

family planning and also supply contraceptives.

Administrative officer-1
Village level:
At the village level, there are village health guides and trained dais. Village health guides
are mostly women, one for each village or for a population of 1000. They provide motivation
Clerk and ancillary staff-1
for family planning and supply oral pills. Trained dais local birth attendants (females) who are
trained for conducting deliveries. They act as family planning counselors and motivators.

ROLE OF NURSE IN FAMILY WELFARE PROGRAM:

The nursing personnel have various functions and responsibilities at different levels with
regard to family planning. These are as follows:
1. As a nurse administrator:
 Maintains an up-to-date and relevant knowledge about family planning services in
the country
 Make sure that all her nursing staff are aware of family planning measures during
their training or in-service education program
 Ensures that adequate educational material on family planning is available in the
ward library and all contraceptives methods for demonstration to patients are made

39
 available in the wards.Formulate a policy on imparting knowledge on family
welfare services to all patients before they are discharged from the hospitals.
 Establishes a good referral system between each ward of the hospital and the
family planning department so that each eligible client gets required
contraceptives.
 Incentivizes nurses to make their best contributions to family planning services.
 Supervises nurses, ANMs, Anganwadi workers and multipurpose health workers in
relation to activities on family planning.
 Participation or conducts research on family planning.
 Plans and conducts in-service education programs for nursing personnel.
2. As a nurse educator:
 Integrates family planning component in nursing curriculum while teaching.
 Teaches family planning as a subjects.
 Selects and organizes learning experience both in theory and practice for student
nurses.
 Coaches ANM, health visitors, multipurpose health workers and Anganwadi
workers regarding family planning
 Help nurse administer to organize in-service education programs for nurses
 Also clarifies doubts of patients regarding family planning, during her supervisory
rounds
 Conducts or participates in nursing research on family planning
3. As a clinical nurse in hospital/community:
 Identifies eligible couples.
 Imparts information to the eligible couples regarding different methods of
contraception advantages, disadvantages and side effect
 Motivates the couple to adopt family planning methods
 Counsels the couple to identify their problems due to large family and take steps to
solve those problems
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  Assist the doctor in surgical methods such as vasectomy and tubectomy
 Maintain the stock book and ensures adequate supplies in health care center
 Manage referral services and follow-up-care
 Maintain properly the documents and records of vital statistics.
4. As a research worker:
 Conducts surveys of eligible couples from different communities with varying
socio-economic data
 Studies the attitude of community toward the family planning
 Organizes surveys on knowledge of family planning among patients in hospital
setting
 Imparts sex education on adolescents
 Participate in or conducts studies on family planning and other related topics.

COUNSELING FOR FAMILY WELFARE:

Nurses plays an important role in counseling couples for family planning.
 Respect the couple and help them to now all the methods of family planning
 Listen and encourage them to explain their needs, concern, and problems
 Let the couple talk and lead the discussion
 Give correct information in simple language
 Give cafeteria approach in choosing the methods. (In cafeteria approach, all the methods
are demonstrated to the couple with the explanation of their advantages and
disadvantages. The couple can then select a method according to their choice there is no
coercion) the way we choose a food item from the menu book in a restaurant.
 Inform the client about the effects and side effects of each method or the chosen method
 Respect and appreciate the client on their informed decision
 Check the client’s feedback and respond immediately
 Give proper referral health facility, if required

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  Before the client’s leave ensure that they are statisfied
 Distributes supplies

INDEPENDENT NURSE MIDWIFERY PRACTITIONER

INTRODUCTION:
Activities of health care providers who are experts in the women health care including
prenatal care to expectant mothers, attending at birth and providing post partum care to mother
and infant. Practitioners of midwifery are known as midwives.
Independent midwifery practice enables registered nurse midwives to utilize their
knowledge skills, judgment and authority in the provision of midwifery practice package and
primary women’s health services while maintaining accountability for the management of
patient care in accordance with midwifery standards laid down by the midwifery or nursing
council of their country.
Independent should not interpret to mean alone, as there are clinical situations when any
prudent practitioner would seek the assistance of other qualified.

MIDWIFERY PRACTICE PACKAGE FOR INDEPENDENT PRACTICE:

 Access to a midwife 24 hours a day, 7 days a week.
 Two midwives available alternatively and provide women centered antenatal,
intrapartum and postnatal midwifery care.
 Antenatal care in privacy.
 Continuity of care throughout labour.
 Postnatal care up to 6 weeks.
 Knowledgeable breast feeding support.
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STANDARDS REQUIRED FOR THE PRACTICE OF MIDWIFERY:
 Midwifery practice as conducted by midwife is the independent management of women’s
health care, focusing particularly on pregnancy, child birth the postpartum period care of
newborn, family planning and gynecological needs of women.
 Midwives provide consultation, management, collaborative management or referral as
indicated according to standards of midwifery practice.
 In India as such standards of midwifery practice act are not developed to do independent
midwifery practices which are one of the essential requirements. American college of
nursing midwives has defined eight standards of practice.

STANDARD- I:
o Midwifery care is provided by qualified practitioners.
o Midwifery should be registered.
o Shows evidence of continuing competency as required by certification agency by
council.
o It is in compliance with the legal requirements of the jurisdiction where the midwifery
practice occurs.

STANDARD- II:
o Midwifery care occurs in a safe environment within the context of the family, community
and a system of health care.
o Demonstrate a safe mechanism for obtaining medical consultation, collaboration and
referral.
o Uses community services as needed.
 Demonstrates knowledge of the medical, psychological, economical, cultural and family
factors that affect care.

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 Demonstrates appropriate techniques for emergency management including arrangements
for emergency transportation.
 Promotes involvement of support persons in the practice settings.

STANDARD- III:
o The midwives practices in accordance with the philosophy and the code of ethics of the
professional body provides clients with a description of the scope of midwifery services
and information regarding the client’s rights and responsibilities.
o Provides clients with information regarding services when requested or when care
required is not within the midwife’s scope of practice.
o Provides client with information regarding health care decisions and the state of science
regarding these choices to allow for informed decision making.

STANDARD- IV:
o Midwifery care is comprised of knowledge, skills and judgment that foster the delivery of
safe satisfying and culturally competent care.
o The midwife collects and assesses client care data, develops and implement
individualized plan of management and evaluates outcome of care.
o Demonstrates the clinical skills and judgments described in the basic midwifery practice.
Practices in accordance with standards. Practices in accordance with service or practice
guidelines that meet the requirements of the particular institution or practice settings.

STANDARD- V:
o Midwifery care is based upon knowledge, skills and judgment which are reflected in
written practice guidelines.
o Midwife describes the parameters of services for independent and collaborative
midwifery management and transfer of care when needed.

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 o Establish practice guidelines for each specialty area which may include, but is not care of
the child bearing family and newborn care.
o Includes the following information in each specialty area :
 Client selection criteria.
 Parameters and methods for assessing health status.
 Parameters for risk assessment.
 Parameters for consultation, collaboration and referral.
 Appropriate interventions including treatment, medications and or devices.

STANDARD- VI:
o Midwifery care is documented in a format that is accessible and competent.
o The midwife uses records that facilitate communications and institutions.
o Provides prompt and complete documentation of evaluation, course of management and
outcome of care.
o Promotes documentation system that provides for confidentiality and transmissibility of
health records.
o Maintain confidentiality in verbal and written communications.

STANDARD- VII:
o Midwifery care is evaluated according to an established programme for quality
management that includes a plan to identify and resolve problems.
o The midwife participates in programme of quality management for the evaluation of
practice within the setting in which it occurs.
o Provides for a systemic collection of practice data as a part of a programme of quality,
management.
o Seeks consultation to review problems, including peer review of care.
o Acts to resolve problems identified.

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STANDARD- VIII :
o Midwifery practice may be extended beyond the set competencies to incorporate new
procedure that improve care for women and their fames.
o The midwife identifies the need for new procedure taking into consideration consumer
demand, standards for safe practice and availability of other qualified personnel.
o Ensures that there are no institutional state or council statures, regulations or laws that
would constrain the midwife from incorporation of the procedure into practice.

CONCLUSION

There is still scope for improving the utilization of Family Welfare

Services and the predictors identified in the present study for utilization/ non -
utilization of the same can be thoroughly scrutinized for planning targeted interven
tions.
The family welfare programme has high priority in India because its success
depends upon the quality of life of all citizens. FWP mainly includes: Family
planning information, counselling and services to women for healthy reproduction.
A very limited success has been achieved in curbing the birthrate and in
creating an awareness of the population problem and of family planning methods
among the masses. A gap between knowledge of contraceptive methods and the
practice of such methods exists.
The Family Planning Programme in India is free and voluntary in nature, and
it is the citizen's prerogative to choose a family planning method best suited to them
based on their reproductive rights.

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BIBLIOGRAPHY
1. Dutta D C, “TEXTBOOK OF OBSTETRICS”, 8th edition, Jaypee Brothers
publication, New Delhi. Page No: 609-640.
2. Kour Sandeep, TEXTBOOK OF MIDWIFERY AND OBSTETRICAL
NURSING, CBS Publication, 1st edition, 2020-21, New Delhi, Page No:620-
656.
3. Kumari Neelam, Textbook of “COMMUNITY HEALTH NURSING-II”, 4 th
edition, 2013, P V publication, New Delhi, Page No: 452-498.
4. Google references:
 SCRIBD PDF’s : Vital statistics, Recent advancement in
contraceptive technology and Role of independent nurse
midwifery practitioner.

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