INDIA

B.Sc., M.B.B.S., D.P.H., D.I.H.,PGCH&FW(NIHFW)

INDIAN RAILWAY MEDICAL SERVICE
Post Graduate student in Community Medicine(M.D)
Department of Community Medicine / SRMC & RI (DU )
 MILES STONE IN MCH CARE IN INDIA
• 1880 – ESTABLISHMENT OF TRAINING OF DAIS IN AMRITSTAR
• 1902 - 1st MIDWIFERY ACT TO PROMOTE SAFE DELIVERY
• 1930 - SETTING UP OF ADVISORY COMMITTEE ON MATERNAL
MORTALITY.
• 1946 - BHORE COMMITTEE RECOMMENDATION ON
COMPREHENSIVE & INTEGRATED HEALTH CARE
• 1952 – PRIMARY HEALTH CENTER NET WORK & FAMILY PLANNING
PROGRAMME
• 1956 – MCH CENTERS BECOME INTEGRAL PART OF PHCS
• 1961 - DEPARTMENT OF FAMILY PLANNING CREATED
• 1971 – MTP ACT
• 1974 – FAMILY PLANNING SERVICES INCORPORATED IN MCH CARE
• 1977 – RENAMING FAMILY PLANNING TO FAMILY WELFARE
• 1978 – EXPANDED PROGRAMME ON IMMUNIZATION
• 1985 – UNIVERSAL IMMUNIZATION PROGRAMME
• 1992 – CHILD SURVIVAL& SAFE MOTHERHOOD PROGRAMME
• 1996 – TARGET FREE APPROACH
• 1997 – RCH PROGRAMME PHASE-1
• 2005 – RCH PROGRAMME PHASE-2
TOTAL 846.3(Census 1028.6
POPULATION(IN 1991) (Census
MILLIONS) 2001)
SEX RATIOS 927 (Census 933(Census
(FEMALES/1000) 1991) 2001)

CRUDE BIRTH 29.5 (SRS 25 (SRS

RATE 1991) 2001)
(PER1000POPULA
TION)
CRUDE DEATH 9.8 (SRS 8.1(SRS
RATE(PER1000 1991) 2001)
POPULATION)
 MATERNAL MORTALITY

Death of a woman while pregnant or

with in 42 days of termination of
pregnancy irrespective of duration &
site of pregnancy from any cause
related to or aggravated by pregnancy
or its management but not from
accidental or incidental causes.
 MAJOR CAUSES OF M.M.R
• DIRECT CAUSES
• HEMORRHAGE – 29.6%
• PUERPERAL COMPLICATION – 16.1%
• OBSTRUCTED LABOUR – 9.5%
• ABORTIONS – 8.9%
• TOXAEMIA OF PREGNANCY 8.3%
• INDIRECT CAUSES
• Anaemia
• Pregnancy with TB
• Pregnancy with malaria
• Pregnancy with viral hepatitis
MMR IN SELECTED COUNTRIES (2000)

COUNTRY MMR(1L/LB)

INDIA 407
SRI LANKA 92
BANGALADESH 380
NEPAL 740
CHINA 56
JAPAN 10
SINGAPORE 15
UK 14
USA 14
SWITZERLAND 7
ESTIMATED MMR –MAJOR STATES –INDIA(2000)

STATES MMR/1L LB
ANDHRA PRADESH 154
BIHAR 451
GUJARAT 29
KARNATAKA 195
KERALA 195
MADHYA PRADESH 498
RAJASTAN 677
TAMIL NADU 76
UTTAR PRADESH 707
 DISPARITY OF MATERNAL DEATH BETWEEN
DEVELOPED & DEVELOPING COUNTRIES
• BARRIER TO RECEIVE TIMELY & GOOD QUALITY
CARE
• BARRIER OF AVAILABILITY AND ACCESSIBILITY OF
SERVICES
• POLITICAL BARRIER
• GEOGRAPHICAL BARRIER
• CULTURAL BARRIER
• WOMEN’S LITERACY AND WOMEN EMPOWERMENT
• TIME BARRIER
• ECONOMIC BARRIER
• BARRIER TO HAVE HEALTH PERSONNEL AT GRASS
ROOT LEVEL
RCH – Ι PROGRAMME
15.10. 1997
Objectives
· Reduction of Maternal Morbidity and
Mortality (MMR)
· Reduction of Infant Morbidity and
Mortality (IMR)
· Reduction of Under 5 Morbidity and
Mortality (U5MR)
· Promotion of adolescent health
· Control of reproductive tract infections
and sexually transmitted infections.
• The first phase of the programme had
started from 1997
• To bring down the birth rate below 21
per 1000 population
• To reduce the infant mortality rate
below 60 per 1000 life born
• To bring down the maternal mortality
rate below 400 per one lakh.
• Eighty per cent institutional delivery,
• 100 per cent antenatal care
• and 100 per cent immunization of
children
 Target Oriented Goal Oriented

Performance by Performance by
Numbers Quality

• Top Down • Bottom up

• Client Need Based
• Target Driven
• Community
Participation
• To the Govt. System • To the Clients,
Community
 COMPONENTS OF RCH PROGRAMME

• Prevention and management of unwanted

pregnancy
• Maternal care that includes antenatal, delivery, and
postpartum services
• Child survival services for newborns and infants
• Management of reproductive tract infections and
sexually transmitted infections
REPRODUCTIVE HEALTH ELEMENTS

• Responsible and healthy sexual behaviour

• Intervention to promote safe motherhood
• Prevention of unwanted pregnancy
• To increase accessibility of contraceptives
• Safe abortions
• Pregnancy and delivery services
• Management of RTI/STD
• Referral facility by government/private
sector for pregnant women at risk
• Reproductive health services for
adolescents
• Screening and treatment of infertility,
cancer & other gynecological disorders
 CHILD SURVIVAL ELEMENTS
• Essential New Born Care
• Prevention and management of vaccine
preventable disease
• Urban measles campaign
• Neonatal tetanus elimination
• Surveillance of vaccine preventable diseases
• Cold chain system
• Polio eradication : pulse polio programme
• ARI control programme
• Diarrhea control programme and ORS programme
• Prevention and control of Vitamin A deficiency
among children
• Baby Friendly Hospital Initiative (BFHI)
 STRATEGY
• BOTTOM-UP PLANNING
• COMMUNITY NEED ASSESSMENT
APPROACH
• DECENTRALISED PARTICIPATORY
PLANNING & IMPLEMENTATION
• STRENGTHENING INFRASTUCTURE
• INTEGRATED TRAINING PACKAGE
• IMPROVED MANAGEMENT SYSTEM
• INTERVENTIONS
• MONITORING & EVALUATION
 ANTE NATAL CARE
• Early registration of pregnancies (12 – 16 weeks)
• Minimum 3 antenatal visits (20,32,36 weeks) check-
ups
• Anaemia prophylaxis ( Iron and Folic acid tablets)
• Two doses of TT
• Minimum investigations( Weight, B.P,Blood group, Rh
typing, Urine examination,VDRL,HIV (TRIDOT TEST)
• Identification of high risk group, Early detection of
complication of pregnancy & timely , safely referral
to FRU
• Treatment of worm infestation with Mebendazole
• Health education on diet, breast feeding, care of
breast, personnel hygiene during pregnancy,& family
planning
 REFERAL

1. BLEEDING 1.FIRST LEVEL

REFERRAL CENTER
2. OBSTRUTED LABOUR
2.COMMUNITY
HEALTH
CENTER/DISTRIC
HOSPITAL
1. SEPSIS
2. TOXAEMIA PRIMARY HEALTH
3. ABORTION CENTER

1.ANAEMIA SUB CENTER

2.FAMILY PLANNING
 COMPLICATIONS DURING ANTE-NATAL, INTRA NATAL, AND POST
NATAL PERIOD & WHERE TO REFER
AVERAGE TIME INSTITUTION TO
COMPLICATIONS FROM ONSET TO WHICH TO BE
DEATH REFRRED
1.APH 12 HRS FIRST LEVEL
2.PPH 2 HRS REFERAL CENTER

SEVERE 2 DAYS PHC/CHC

TOXAEMIA
RUPTURED 24 HRS FLRC
UTERUS
OBSTRUCTED 3 DAYS FLRC
LABOUR
SEPSIS ( AFTER 6 DAYS PHC/ CHC/FLRC
ABORTION,
DELIVERY)
SEVERE ANAEMIA 2 HRS TO 1 DAY FLRC
( CHF IN LABOUR)
PACKAGES OF SERVICES AT FRU
•VACCUM EXTRACTIONS
•ADMINISTRATION OF ANAESTHESIA
•BLOOD TRANSFUSION
•CASEAREAN SECTION
•MANUAL REMOVAL OF PLACENTA
•CARRY OUT SUCTION CURETTAGE FOR INCOMPLETE
ABORTION
•INSERTION OF INTRAUTERINE DEVICES
•STERILIZATION OPERATION
 TYPES OF KIT for FRU
•Kit-E – Laparotomy set
•Kit-F - Mini– Laparotomy set
•Kit-G – IUD insertion set
•Kit-H – Vasectomy set
•Kit- I – Normal delivery set
•Kit- J – Vacuum extraction set
•Kit- k – Embryotomy set
•Kit- L – Uterine evacuation set
•Kit-M – Equipment for anesthesia
•Kit-N- Neonatal resuscitation set
•Kit-O- Equipment and reagent for blood test
•Kit-P – Donor blood transfusion set
 INTRANATAL CARE

• Delivery by trained personnel

(100%)
• Institutional delivery (80%)
• Care at birth ( Five cleans:
Clean Birth Canal,Clean surface
for delivery,Clean Hands,Clean
Cutting, & Clean Cord)
 POST NATAL CARE

• 3 post natal check-ups of mothers after

delivery
• Breast feeding – early & exclusive breast
feeding
• Spacing – minimum 3 years between two
pregnancies
 NEW STRATEGY
• EMPOWERED ACTION GROUP HAS BEEN
CONSITUTED ON 20.03.2001
• TRAINING OF DAIS IN 156 DISTRICTS 18 STATES/UTs
2001-2002
• RCH CAMPS & RCH OUT REACH SCHEME
• GADCHIROLI MODEL TO TAKE CARE OF HOME
BASED NEONATEL CARE IN 2002
• KANGAROO MOTHER CARE TO TAKE CARE OF LOW
BIRTH WEIGHT INFANTS
• BORDER DISTRICT CLUSTER STRATEGY – 49
DISTRICTS/17 STATES
• INTEGRATED MANAGEMENT OF CHILDHOOD
ILLNESS STRATEGY TO TAKE CARE OF SICK
NEWBORNS
 STEPS TO REDUCE MATERNAL
MORTALITY
• HEALTH SECTOR ACTIONS
 Basic antenatal , intra natal &post natal care.
 skilled attendants @ every birth.
 EOC & Comprehensive obstetric care.
 Prevention of unwanted pregnancy &unsafe
abortions.
 Joint consultations -medical disorders.
 Maternal mortality audit .
 STEPS TO REDUCE
• COMMUNITY , SOCIETY & FAMILY ACTIONS .

• HEALTH PLANNERS /POLICY MAKERS ACTIONS

 community education ,motivation.
 Strengthen referral system.
 management protocols for obstetric
emergencies.
 CME – Improve quality & standard of care.
 Maternal mortality audit .
 STEPS TO REDUCE
• LEGISLATIVE & POLICY ACTIONS

 Girl children & adolescents :

nutrition , cducation ,economic opportunities.
 Remove barriers to access health care.
 Cost
 Socio cultural factors
 Safe abortions & post abortion care -MVA
 Remove social inequalities- gender , age
marital status.
 ACHIVEMENT OF H & FW INDICATORS IN TAMILNADU(
1997-2002)
• LIFE EXPECTANCY AT BIRTH – 65
• CRUDE BIRTH RATE – 19.2
• CRUDE DEATH RATE – 7.9
• NATURAL GROWTH RATE – 1.1
• INFANT MORTALITY RATE – 51
• UNDER FIVE MORTALITY RATE – 15.1( R )9.7( U )
• MATERNAL MORTALITY RATE – 1.3
• TOTAL FERTILITY RATE – 1.95
• COUPLE PROTECTION RATE – 51.6
• MEAN AGE AT MARRIAGE – 21.2
• ANTE NATAL CARE – 98.5%
• POST NATAL CARE – 90%
• INSTITUTIONAL DELIVERY – 87.6%
• DELIVERY BY TRAINED STAFF – 98%
• PNMR –43/1000
• NNMR – 38/1000
• % OF LOW BIRTH WEIGHT BABIES –17%
• AVERAGE BIRTH WEIGHT OF BABIES – 2.7 KG
• STILL BIRTH RATE – 11.7/1000
• IMMUNIZATION COVERAGE –100%
World Health Day 2005 Slogan
Make Every Mother And Child Count
Reflects that health of women
and children should be given
higher priority at all levels of
health care system.

Every one is accountable for

health of mothers & children
RCH - II PROGRAMME

01-04-2005
 THE 5 YEAR PHASE OF RCH II

VISION To bring about outcomes as

envisioned in the
1. Millennium Development Goals
2. The National Population Policy 2000
(NPP 2000)Goals
3. The Tenth Plan Goals
4. The National Health Policy 2002
5. and Vision 2020 India
 1728 - FRU

PHC-22928

SUB CENTER-
38044
1. MATERNAL HEALTH
a) 260 Primary Health Centres are proposed to be taken up for
improving access to Essential Obstetric and New Born Care
services round the clock in TN. All CHC, & 50% PHCs to be
made functional for 24 hrs delivery services,& 2000 FRU are
proposed
b) Improving quality of antenatal, neonatal and postnatal care
by providing increased number of antenatal checkups, fixed
day antenatal clinics, linking visits of neonates with
postnatal care, empowering the VHNs in performing
obstetric first aid and newborn care.
c) Improvement of the referral networking systems by
establishing emergency help line.
d) Regular conduct of blood donation camps for the continued
availability of blood in the blood banks.
e) Universalizing the concept of birth companionship during the
process of labour in all health facilities conducting deliveries.
f) Operationalisation of maternal death audit to address the
INFANT AND CHILD HEALTH
a. Reduction of new-born deaths, infant deaths
and child deaths by providing continuous health
care and strengthening of new-born care
infrastructure facilities.
b. Organizing counselling sessions for the
mothers.
c. Implementing integrated management of
neonatal and childhood illness as a pilot
initiative in selected districts in Tamil Nadu.
d. Operationalising infant death/stillbirth verbal
autopsy.
e. Addressing the issue of female infanticide and
foeticide.
3. ADOLESCENT HEALTH.
a) Focusing adolescents as receivers and
providers of knowledge and function as link
volunteers in the community.
b) Utilising the services of trained
adolescents for propagating Indian System of
Medicines.
c) Broadcasting and Telecasting of
programme by AIR/TV focusing adolescent,
gender and health related subjects.
d) Formation of co-ordination committee at
the district level and monitoring committee at
the State level for overseeing the AIR/TV
programme.
 FAMILY WELFARE
a)While sustaining the ongoing family welfare
interventions in all districts, 19 districts with Higher
order births will be targeted for intensified
interventions.
b) Social marketing programme for condom and other
health commodities, promotion of IUD insertions,
familiarizing the concept of one-stop Family Welfare
Centre.
c) Increasing access to safe abortion services by
popularising manual vacuum aspiration (MVA)
technique.
d) Establishment of one-stop family welfare services at
Comprehensive Emergency Obstetric and New Born
Care (CEMONC) Centres.
e) Popularizing No Scalpel Vasectomy.
5. Reproductive tract infections / Sexually
transmitted infections / Cancer control.

a) Establishment of Reproductive Tract

Infection / Sexually Transmitted Infection,
early Cancer detection clinics .
b) Strengthening RCH outreach services.
c) RTI/STD clinic in selected 70 primary
health centers
Infrastructure strengthening for service
delivery
a) Construction of HSC buildings where HSCs are
currently functioning in rented premises
b) Rebuilding HSCs which are unfit for occupation.
c) Taking up of repairs/renovation and provision of
water supply/electrical works to PHCs/HSCs.
d) Need-based supply of equipment/furniture to the
HSCs and PHCs as per the standard list including gas
connections.
e) Provision of Cell phones to HSCs where large
number of deliveries take place.
f) Provision of telephones to PHCs
TRAINING
a) Skill upgradation training with focus
on improving/upgrading the skills of
health care providers.
b) Integrated skill training for peripheral
health functionaries such as VHNs, SHNs,
medical officers and health inspectors.
c) Improving managerial and
communication skills of health staff.
BEHAVIOURAL CHANGE COMMUNICATION
(BCC)
a) Social mobilisation activity against female
infanticide and foeticide by preventive
counselling.
b) Formation of HSC, Block, District level
committees for saving female babies.
c) Conducting of Kalaipayanam (travelling
street theatre) to promote social mobilization
and to improve health care among the target
population
d) Telecasting of TV serials, Radio broadcasts,
wall paintings, hoardings and glow signs for
popularizing health and reproductive health
messages in important places.
HEALTH MANAGEMENT INFORMATION SYSTEMS
Introduction of IT-enabled HMIS for planning and
monitoring health services at the State/District
/Block levels
STRENGTHENING OF TEACHING INSTITUTIONS
Strengthening the facilities at teaching institutions
for providing optimum obstetric, family welfare,
neonatal child health services.
ESTABLISHING URBAN HEALTH POSTS
To provide an integrated and sustainable system for
primary health care service delivery catering to the
requirements of urban slum population and other
vulnerable groups
HEALTH FINANCING
The health care expenditure in India
currently stands at 6.1% of GDP. The
private out of pocket expenditure
being 4.7% of Gross Domestic
Product (GDP). The total government
expenditure on family welfare has
shown an increasing trend from 4.9
billion in fifth plan (1974-79) to Rs.
271.25 billion in the tenth plan
(2002-07)
 ACCESSIBILITY INDICATOR
•No. of eligible couples registered/ANM
•No. of Antenatal Care sessions held as planned
•% of sub Centers with no ANM
•% of sub Centers with working equipment of
ANC
•% ANM/TBA without requisite skill
•% sub centers with DDKs
•% of sub centers with infant weighing
machine
•% subcenters with vaccine supplies
•% sub centers with ORS packets
•% sub centers with FP supplies
 QUALITY INDICATOR
•% Pregnancy Registered before 12 weeks
•% ANC with 5 visits
•% ANC receiving all RCH services
•% High risk cases referred
•% High risk cases followed up
•% deliveries by ANM/TBA
•%PNC with 3 PNC visits
•% PNC receiving all counselling
•% PNC complications referred
•% Eligible couple offered FP choices
•% women screened for RTI/STDs
•% Eligible couple counselled for prevention of RTI/STDs
•% ADD given ORS
•% ARI treated
•% children fully immunized
 IMPACT INDICATOR
•% DEATHS FROM MATERNAL CAUSES
•MATERNAL MORTALITY RATIO
•PREVALENCE OF MATERNAL MORBIDITY
•% LOW BIRTH WEIGHT
•NEO-NATAL MORTALITY RATIO
•PREVALENCE OF POST NATAL MATERNAL MORBIDITY
•% BABY BREAST FEED WITHIN 6 HRS OF DELIVERY
•COUPLE PROTECTION RATE
•PREVALENCE OF TERMINAL METHOD OF
STERILIZATION
•PREVALENCE OF SPACING METHOD
•% ABORTION RELATED MORBIDITY
•PREVALENCE OF ADD
•PREVALENCE OF ARI
•PREVALENCE OF RTI/STDs
THANK YOU