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 POPULATION(IN MILLIONS) SEX RATIOS (FEMALES/1000) 846.3(Census 1991) 1028.6 (Census 2001) 927 (Census 1991) 933(Census 2001) CRUDE BIRTH RATE (PER1000POPULA TION) CRUDE DEATH RATE(PER1000 POPULATION) 29.5 (SRS 1991) 9.8 (SRS 1991) 25 (SRS 2001) 8.1(SRS 2001)

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 INDIA SRI LANKA BANGALADESH NEPAL CHINA JAPAN SINGAPORE U K USA SWITZERLAND MMR(1L/LB) 56 10 15 14 14 7 407 92 380 740

ESTIMATED MMR –MAJOR STATES –INDIA(2000) STATES ANDHRA PRADESH BIHAR GUJARAT KARNATAKA KERALA MADHYA PRADESH RAJASTAN TAMIL NADU UTTAR PRADESH MMR/1L LB 154 451 29 195 195 498 677 76 707

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 Performance by Numbers Top Down Target Driven

•

To the Govt. System Goal Oriented Performance by Quality

• • •

Bottom up Client Need Based Community Participation

•

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 2. OBSTRUTED LABOUR

1

.

FIRST LEVEL REFERRAL CEN TER 2.COMMUNITY HEALTH CEN TER/DISTRIC HOSPITAL 1. SEPSIS 2. TOXAEMIA 3. ABORTION PRIMARY HEALTH CEN TER

1.

ANAEMIA 2.FAMILY PLANNING SUB CEN TER

COMPLICATIONS DURING ANTE-NATAL, INTRA NATAL, AND POST NATAL PERIOD & WHERE TO REFER COMPLICATIONS AVERAGE TIME FROM ONSET TO DEATH INSTITUTION TO WHICH TO BE REFRRED 1.APH

2.PPH

12 HRS 2 HRS FIRST LEVEL REFERAL CENTER PHC/CHC SEVERE TOXAEMIA RUPTURED UTERUS OBSTRUCTED LABOUR SEPSIS ( AFTER ABORTION, DELIVERY) SEVERE ANAEMIA ( CHF IN LABOUR) 2 DAYS 24 HRS 3 DAYS 6 DAYS 2 HRS TO 1 DAY FLRC FLRC PHC/ CHC/FLRC FLRC

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 issues that have led to maternal deaths.

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

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