Provision for maternal and child health under national

Provisions for Maternal and Child health under National Health Mission.RAV I M RP O S T G RA D U AT E ST U D EN T

Saturday, April 8, 2023

1st may 2013


Vision of the NHM“Attainment of Universal Access to Equitable, Affordable and Quality health care services, accountable and responsive to people’s needs, with effective inter- sectoral convergent action to address the wider social determinants of health”

National Health Mission


Sources for framework of NHM

1. It builds on the Framework for Implementation approved by the Cabinet in 2006, for the first phase of the NRHM

2. Learning from NRHM implementation over the past seven years, documented in several evaluation reports and studies and the experiences of people and practitioners across the rural areas of the country

3. Chapter on Health of the Twelfth Plan provides the broad guidance for this Framework


Core Values

• Safeguard the health of the poor, vulnerable and disadvantaged, and move towards a right based approach to health through entitlements and service guarantees

• Strengthen public health systems as a basis for universal access and social protection against the rising costs of health care.

• Build environment of trust between people and providers of health services


• Empower community to become active participants in the process of attainment of highest possible levels of health.

• Institutionalize transparency and accountability in all processes and mechanisms.

• Improve efficiency to optimize use of available resources


Goals of National Health Mission

1) Reduce MMR to 1/1000 live births

2) Reduce IMR to 25/1000 live births

3) Reduce TFR to 2.1

4) Prevention and reduction of anaemia in women aged 15–49 years

5) Prevent and reduce mortality & morbidity from communicable, noncommunicable diseases; injuries and emerging diseases


6) Reduce household out-of-pocket expenditure on total health care expenditure

7) Reduce annual incidence and mortality from Tuberculosis by half

8) Reduce prevalence of Leprosy to <1/10000 population and incidence to zero in all districts

9) Annual Malaria Incidence to be <1/1000

10) Less than 1 per cent microfilaria prevalence in all districts

11) Kala-azar Elimination by 2015, <1 case per 10000 population in all blocks


Provision for Maternal and child health under National Health

Mission


• All schemes and programmes that constituted RCH-II would be absorbed into the NHM.

• NHM provides an opportunity to build on past work and renew the emphasis on strategies for improving maternal and child health through a continuum of care and the life cycle approach.

• The inextricable linkages between adolescent health, family planning, maternal health and child survival have been recognized


• Another dimension of the continuum of care which will receive attention is the linking of community and facility-based care and strengthening referrals between various levels of health care system to create a continuous care pathway.

• All these aspects are embodied in the ‘Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India’.


Maternal Health

• Essential Obstetric Care– Improved access to essential obstretic care through facility development.This includes

quality antenatal care including prevention and treatment of anemia, institutional / safe delivery services and post natal care

• Quality Ante Natal care– Quality ANC includes minimum of at least 4 ANCs including early registration

– 1st ANC in first trimester along with physical and abdominal examinations, Hb estimation and urine investigation , 2 doses of T.T Immunization

– consumption of IFA tablets for 100 days.


• Post natal care for mother and newborn

– Ensuring post natal care within first 24 hours of delivery

– Subsequent home visits on 3rd, 7th,and 42nd day is the important components for identification and management of emergencies occurring during post natal period.

– The ANMs, LHVs and staff nurses are being oriented and trained for tackling emergencies identified during these visits.


• Skilled Attendance at Birth– commitment to provide skilled attendance at every birth both at community and

Institution level.

– To manage and handle some common obstetric emergencies at the time of birth, a policy decision has been taken permitting Staff Nurses (SNs) and ANMs to give certain injections and also perform certain interventions under specific emergency situations to save the life of the mother.

– They are permitted to use following drugs

– Inj Oxytocin, Inj Magnesium sulphate, Inj Gentamicin

– Oral – Metronidazole, Misoprostol, Ampicillin

– Also permitted to start an IV Infusion in emergency


• Provision of Emergency Obstetric and Neonatal Care at FRUs– Provision of Emergency Obstetric and Neonatal Care at FRUs is being done by

operationalziing all FRUs in the country.

– While operationalising, the thrust is on the critical components such as manpower, blood storage units and referral linkages etc.

– Availability of trained manpower (Skill Based Training for MBBS doctors) is linked with operationalization of FRUs


• Augmentation of skilled human resources for Maternal Health:– to overcome the shortage of skilled manpower particularly Anesthetists and

Gynecologists, the following key skill based training programs are being implemented:• An 18 Weeks Training Progamme of MBBS Doctors in Life Saving Anesthesia Skills for

Emergency Obstetric Care.• A 16 weeks Training programme of MBBS Doctors in Obstetric Management Skills

including C-Section, in collaboration with Federation of Obstetric and Gynecological Society of India.(CEmOC).

• A 10 days Training Programme in Basic Emergency Obstetric Care for Medical Officers(BEmOC)

• A 3 weeks Training Programme for ANMs/SNs/LHVs as Skilled Birth Attendants(SBA)


• Referral Services at both Community and Institutional level– establish a network of Basic patient care transportation ambulances with aim to reach

the beneficiary in rural area within 30 minutes of the call for quick service delivery.

– Presently states have been given the flexibility to establish assured referral systems to transport pregnant mothers and sick newborns, etc which includes different models including public, private partnership models


• Safe Abortion Services/ Medical termination of Pregnancy (MTP):– Provision of comprehensive safe abortion services at public health facilities

including 24*7 PHCs/ FRUs (DHs/ SDHs /CHCs) with a focus on "Delivery Points“

– Capacity Building of Medical officers in safe MTP Techniques and of ANMs, ASHAs and other field functionaries to provide confidential counseling for MTP and promote post-abortion care including adoption of contraception.

– District Level Committees have been framed and empowered to accreditate the facilities for conducting safe abortion services under MTP Act including approval of private and NGO sector facilities for conducting MTPs.


– Supply of Nischay Pregnancy detection kits to sub centres for early detection of pregnancy so that safe abortion services can be provided to intended pregnancies covered under the MTP Act.

– Development of standard IEC/BCC material on Safe Abortion.

– Orientation/Training of ASHAs to equip them with skills to create awareness on abortion issues in women and the community and facilitate women in accessing services.


• Provision of RTI/STI services:– provision of STI/RTI care services is a very important strategy to prevent HIV

transmission and promote sexual and reproductive health under the National AIDS Control Program (NACP III) and Reproductive and Child Health (RCH II)

– Enhanced Syndromic case management (ESCM) with minimal laboratory tests is the cornerstone of STI/RTI management under NACP III

– Services are being provided to all FRUs, CHCs and at 24 X 7 PHCs.

– Special focus would be given on linking up with Integrated Counselling and Treatment Centres (ICTCs) and establishing appropriate referrals for HIV testing and RTI/STI management


• Setting up of Blood Storage Centers (BSC) at FRUs:– Timely treatment of complications associated with pregnancy is sometimes hampered

due to non-availability of Blood Transfusion services at FRUs.

– The Drugs and Cosmetics Act has been amended to facilitate establishment of Blood Storage Centers at such FRUs.


• Janani suraksha yojana and Janani Shishu Suraksha Karyakaram (JSSK):– The Janani Suraksha Yojana (JSY) which enables institutional delivery will be

modified in the NHM period to synergize with the new Food Security legislation.

– Another key goal is to move towards UHC through an expanding comprehensive package of free and cashless services currently covering all pregnant women, and sick infants up to the age of one year, in government health institutions through Janani Shishu Suraksha Karyakram (JSSK), thereby reducing financial barriers to care and improving access to health services by eliminating OOP expenditure in all government facilities


• Maternal Death Review:– The process of maternal death review (MDR) has been implemented &

institutionalized by all the States as a policy since 2010.

– Guidelines and tools for conducting community based MDR and Facility based MDR have been provided to the States.

– The States are reporting deaths along with its analysis for causes of death.


• Delivery Points (DPs):– All the States & Union Territories have identified DPs above a certain minimum

benchmark of performance.

– To prioritize and direct resources in a focused manner to these facilities for filling the gaps like trained and

– skilled human resources, infrastructure, equipments , drugs and supplies, referral transport etc. for providing

– quality & comprehensive RMNCH (Reproductive, Maternal, Neonatal & Child Health) services.


• Web Enabled Mother and Child Tracking System:– Name Based Tracking of Pregnant Women and Children has been initiated by

Government of India as a policy decision to track every pregnant woman , infant & child upto 3 yrs, by name for provision of timely

– ANC, Institutional Delivery, and PNC along-with immunization & other related services.


• A Joint MCP Card:– Ministry of

Health & Family Welfare and Ministry of Women and Child Development (MOWCD) has been launched as a tool for documenting and monitoring services for antenatal, intranatal and postnatal care to pregnant women, immunization and growth monitoring of infants.


• Tracking of severe Anaemia during pregnancy & child birth by SCs and PHCs:– severe anemia is a major cause for pregnancy related complications that may

lead to maternal deaths.

– Effective monitoring of these cases by the ANM as well as the Medical Officer in charge of PHC has been started to line list these cases and provide necessary treatment.

• Technical Guidelines & Service Delivery Posters:– GoI has developed & disseminated standard technical guidelines & service delivery

posters for standardizing

– the quality of service delivery during ANC, INC, PNC, etc from tertiary to primary level of institutions.


• Gender Based Violence:– The steps towards enabling a system wide response to gender based violence (GBV)

include: sensitize and train frontline workers and clinical service providers to identify and manage GBV, train ASHAs to identify and refer/counsel cases of GBV in the community,

– develop effective referral mechanisms from primary care to secondary and tertiary centres, with assured services, build functional referral linkages and create follow up mechanisms with government departments and NGOs providing legal and social welfare services and women’s support groups in the district.


New Born and Child Health

• Thrust Area 1 : Neonatal Health– Essential new born care (at every ‘delivery’ point at time of birth)

– Facility based sick newborn care (at FRUs & District Hospitals)

– Home Based Newborn Care

• Thrust Area 2 : Nutrition– Promotion of optimal Infant and Young Child Feeding Practices

– Micronutrient supplementation (Vitamin A, Iron Folic Acid)

– Management of children with severe acute malnutrition


• Thrust Area 3: Management of Common Child hood illnesses– Management of Childhood Diarrhoeal Diseases & Acute Respiratory Infections

• Thrust Area 4: Immunisation– Intensification of Routine Immunisation

– Eliminating Measles and Japanese Encephalitis related deaths


Facility based new born and child care

• Special Newborn Care Units (SNCU)– states have been asked to set up at least one SNCU in each district. SNCU is 12-20

bedded unit and requires 4 trained doctors and 10-12 nurses for round the clock services

• Newborn Stabilization units (NBSUs)– NBSUs are established at community health centres /FRUs. These are 4 bedded units

with trained doctors and nurses for stabilization of sick newborns.

• New Born Care Corners (NBCCs)– These are 1 bedded facility attached to the labour room and Operation Theatre (OT)

for provision of essential newborn care. NBCC at each facility where deliveries are taking place should be established.


• Janani suraksha karyakram– janani Shishu Suraksha Karyakram (JSSK) was launched on 1st June 2011and has

provision for both pregnant women and sick new born till 30 days after birth are

– (1) Free and zero expense treatment,

– (2) Free drugs and consumables,

– (3) Free diagnostics & Diet,

– (4) Free provision of blood,

– (5) Free transport from home to health institutions,

– (6) Free transport between facilities in case of referral,

– (7) Drop back from institutions to home,

– (8) Exemption from all kinds of user charges.


• Integrated management of Neonatal and Child hood illness:– Improvement in case management skills of health staff

– Improvement in health system

– Improvement in family and community practices

– ASSESS THE CHILD

– CLASSIFY CHILD’S ILLNESS Using colour coded triage system:


• F-IMNCI– F-IMNCI is the integration of the Facility based Care package with the IMNCI

package

– focuses on providing appropriate skills for inpatient management of major causes of Neonatal and Childhood mortality such as asphyxia, sepsis, low birth weight and pneumonia, diarrhea, malaria, meningitis, severe malnutrition in children

– This training is being imparted to Medical officers, Staff nurses and ANMs at CHC/FRUs and 24x7 PHCs where deliveries are taking place. The training is for 11 days.


• Home Based New Born care:– ASHA will make visits to all newborns according to specified schedule up to 42 days

of life

– Recording of weight of the newborn in MCP card

– ensuring BCG , 1st dose of OPV and DPT vaccination

– both the mother and the newborn are safe till 42 days of the delivery, and

– registration of birth has been done


• Navjaat Shishu Suraksha Karyakram(NSSK):– NSSK is a programme aimed to train health personnel in basic newborn care and

resuscitation.

– has been launched to address care at birth issues i.e. Prevention of Hypothermia, Prevention of Infection, Early initiation of Breast feeding and Basic Newborn Resuscitation

– The objective of this new initiative is to have a trained health personal in Basic new born care and resuscitation at every delivery point.

– The training is for 2 days and is expected to reduce neonatal mortality significantly in the country.


• Infant and Young child Feeding:– Infant and Young Child Feeding is the single most preventive intervention for child

survival. It advocates the following:-• Early initiation (within one hour of birth) and exclusive breast feeding till 6 months.• Timely complementary feeding after 6 months with continued breast feeding till the age of

2 yrs.


• Nutrition rehabilitation centres:– treat severe acute malnutrition amongst children

– Nutritional Rehabilitation Centres (NRCs) are being set up in the health facilities for inpatient management of severely malnourished children, with counselling of mothers for proper feeding and once they are on the road to recovery, they are sent back home with regular follow up.


• Reduction in morbidity and mortality due to acute respiratory tract infections and diarrheoal diseases.– Childhood Diarrhoea

• India introduced the low osmolarity Oral Rehydration Solution (ORS), as recommended by WHO for the management of diarrhea.

• Zinc has been approved as an adjunct to ORS for the management of diarrhea. Addition of Zinc would result in reduction of the number and severity of episodes and the duration of diarrhoea.

• New guidelines on management of diarrhoea have been modified based on the latest available scientific evidence


– Acute Respiratory Infections• Acute Respiratory Infections forms 19 % of all under five mortalities in India (WHO 2007

report) and along with Diarrhoea are two major killers of under five children.• Early diagnosis and appropriate case management by rational use of antibiotics remains one

of the most effective interventions to prevent deaths due to pneumonia.


• Supplimentation with Micronutrients:– Vitamin – A

• The policy has been revised with the objective of decreasing the prevalence of Vitamin A deficiency to levels below 0.5%,

– the strategy being implemented is:1,00,000 IU dose of Vitamin A is being given at nine months

– Vitamin A dose of 2,00,000 IU (after 9 months) at six monthly intervals up to five years of age

– All cases of severe malnutrition to be given one additional dose of Vitamin A.


• Iron and Folic Acid supplementation:– To manage the widespread prevalence of anaemia in the country, the policy has been

revised.

– Infants from the age of 6 months onwards up to the age of five years shall receive iron supplements in liquid formulation in doses of 20mg elemental iron and 100mcg folic acid per day per child for 100 days in a year.

– Children 6-10 years of age shall receive iron in the dosage of 30 mg elemental iron and 250mcg folic acid for 100 days in a year.

– Children above this age group would receive iron supplements in the adult dose


Immunization :


• Rashtriya Bal Swasthya Karyakram (RBSK):– Comprehensive child health care implies assurance of extensive health services for all

children from birth to 18 years of age for a set of health conditions

– These conditions are Diseases, Deficiencies, Disability and Developmental delays

–

– Rashtriya Bal Swasthya Karyakram (RBSK) is a new initiative aiming at early identification and early intervention for children from birth to 18 years to cover 4 ‘D’s viz. Defects at birth, Deficiencies, Diseases, Development delays including disability


• First level of screening is to be done at all delivery points through existing Medical Officers, Staff Nurses and ANMs.

• After 48 hours till 6 weeks the screening of newborns will be done by ASHA at home as a part of HBNC package.

• Outreach screening will be done by dedicated mobile block level teams for 6 weeks to 6 years at anganwadis centres and 6-18 years children at school.


• Family Planning– Meeting unmet needs for contraception through provisioning of a range of family

planning methods will be prioritized.

– Family planning services would be utilized as a key strategy to reduce maternal and child morbidities and mortalities in addition to stabilizing population

– Post-partum and post abortion contraception would be a priority. All states would be encouraged to focus on promotion of spacing methods, especially Intra-Uterine Contraceptive Devices (IUCDs)


– Male involvement including male sterilization would be promoted.

– Distribution of contraceptives at the doorstep through ASHAs and other channels will be actively promoted.


• Addressing the Declining Sex Ratio:– stricter enforcement of the PCPNDT Act, improved monitoring and sensitization of

the medical community, and a greater role for civil society action in addressing son preference, addressing neglect of the girl child in illness care, observing sex ratios in hospital admissions for illness in children, and providing proactive support for girl children through the ASHA and Anganwadi system

• Cross cutting areas:– BCC and addressing social determinants is complementary to all the above strategies.

– Human resources and infrastructure requirements for RMNCH +A services would be integrated with the facility strengthening component


Total fertility rate

Maternal Mortality rate


References

• http://nrhm.gov.in/images/pdf/NHM/NRH_Framework_for_Implementation__08-01-2014_.pdf 25-08-2014; 16.00 hrs

• http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/background.html 26-08-2014: 17.00 hrs

• http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html 25-08-2014;17.30 hrs

• http://nrhm.gov.in/images/pdf/programmes/RBSK/For_more_information.pdf 26-08-2014;15.00hrs

• J Kishore. National Health Programs of India. 10th ed. Century Publication. New Delhi. 2012

• Park K. Textbook of Preventive and Social Medicine. 21st ed. Jabalpur(India): Banarsidas Bhanot Publishers; 2011

http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/background.html%2026-08-2014

http://nrhm.gov.in/nrhm-components/rmnch-a/maternal-health/background.html%2026-08-2014

http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html

http://nrhm.gov.in/nrhm-components/rmnch-a/child-health-immunization.html

http://nrhm.gov.in/images/pdf/programmes/RBSK/For_more_information.pdf

http://nrhm.gov.in/images/pdf/programmes/RBSK/For_more_information.pdf

Saturday, April 8, 2023Ravi Varma (1848 – 1906)

Thank you

Provision for maternal and child health under national

Health & Medicine

Transcript of Provision for maternal and child health under national