JUNIOR GROUP PRESENTATION

A MATERIAL ON

NATIONAL HEALTH, FAMILY WELFARE

PROGRAMMES RELATED TO MATERNAL
AND CHILD HEALTH

SUBMITTED TO SUMBITTED BY
MADAM ANGEL THOMAS MS. ANURADHA
TUTOR MSc. NURSING 1ST YEAR
HFCON HFCON
 NATIONAL FAMILY WELFARE PROGRAM
INTRODUCTION
India launched the National Family Planning Program in 1951 to reduce the birth rate at a level
consistent with the requirement of the national economy as a 100 percent centrally sponsored
program.

Evaluation of the Family Welfare Program

The approach under the program during the initial five year plans was to reduce the birth rate by
providing contraception services especially sterilization.

The objective of the 5th plan (1974-1979) was to bring down the birth rate to 30 per 1000 by
integrating family planning services with those of Maternal and Child Health (MCH) and Nutrition
to make the program more, readily acceptable.
The program received a setback during 1977-1978 due to an element of coercion in the
implementation of the program in some areas.

As a result, government made it clear that there was no place for force or coercion or pressure of any
sort under the program and the program had to be implemented as an integral part of Family Welfare
relying solely on mass education and motivation. The name of the program was also changed from
’Family Planning’ to ’Family Welfare’ as per the objective.

In the 6th plan (1980-1985), certain long term demographic goals to be achieved by the year 2000
were
envisaged.

1. Reduction of average family size from 4.4 in 1995 to 2.3 by 2000 AD.

2. Reduction of birth rate to 21 from the level of 33 in 1978, death rate from 14 to 9 and infant
mortality rate from 127 to below 60.

3. Increasing the couple protection level from 22% to 60 per cent.

The Family Welfare Program during the 7th five year plan (1985-1990) was continued on a purely
voluntary basis with emphasis on promoting spacing methods, securing maximum community
participation and promoting maternal and child health care with the following initiatives:

1. It was envisaged to have one subcenter for every 5000 population (3000 population in hilly and
tribal areas). At the end of 7th plan, i.e. 1990, 1.3 lakhs subcenters were established in the country.

2. The postpartum program was extended progressively to subdistrict level hospitals. At the end of
7th plan, 1012 subdistrict level hospitals and 870 health posts were established in the country.

3. The Universal Immunization Program started in 30 districts in 1985-86 was extended to cover all
the districts in the country by the end of VH plan to cover all the districts in the country by 1990.

4. A project was taken up to improve primary health care in urban slums in the cities of Mumbai and
Chennai with assistance from World Bank.
5. Area development projects were implemented in selected districts in 15 major states with
assistance from donor agencies.

The achievements of the Family Welfare Program at the end of 7th plan were:

1. Reduction of crude birth rate from 41.7 (1951-1961) to 30.2 (1990)

2. Reduction in total fertility rate from 5.9 (1950-1961) to 3.8 (1990)

3. Reduction in infant mortality rate from 146 (1970, 1971) to 80 (1990)

4. Increase in couple protection rate from 10.4 per cent (1970-1971) to 43.3 per cent (1990)

5. Setting up of a large network of service delivery infrastructure.

6. Over 118 million births were averted by the end of March 1990.

In the 8th five year plan (1992-1997), several new initiatives were introduced as follows:

1. World Bank assisted Area Projects which seek to upgrade infrastructure and development of
trained manpower. Indian Population Project (IPP) 8th was started aiming at improving health and
family welfare services in urban slums of Delhi, Kolkata, Hyderabad and Bengaluru. IPP 9th will
operate in the states of Rajasthan, Assam and Karnataka.
2. An USAID assisted project named ”Innovation in Family Planning Services” was taken up in
Uttar' Pradesh with the specific objective of reducing total fertility rate (TFR) from 5.4 to 4 and
increasing couple protection rate (CPR) from 35 to 50 per cent over 10 years project period.

3. Greater stress was laid on involvement of NGOs to supplement and complement the Government
efforts in propagating and motivating the people for adoption of small family norm.

The Universal Immunization Program (UIP) was started in 1985 to provide universal immunization
to infants and pregnant women against vaccine preventable diseases. From the year 1992-1993, the
UIP has been strengthened and expanded into the Child Survival and Safe Motherhood (CSSM)
project. It includes sustaining the high immunization coverage level under UIP, and augmenting
activities under Oral Rehydration Therapy (ORT), prophylaxis for control of blindness in children
and control of acute respiratory infections. Under the safe motherhood component, training of
traditional birth attendants. (TBA), provision of aseptic delivery kits and strengthening of first
referral units to deal with high-risk and obstetric emergencies have been taken up.

The targets fixed for the 8th plan of national level birth rate of 26 was achieved by all states except
the states 0f Assam, Bihar, Haryana, Madhya Pradesh, Odisha, Rajasthan and Uttar Pradesh.

In the 9th five-year plan (1997-2002), reduction in the Pcpulation growth had been recognized as one
of the priority objectives. The objectives were:

1. To meet all the unmet needs for contraception.

2. To reduce the infant and maternal morbidity and mortality so that, there is a reduction in the
desired level of fertility.
The strategies during the plan were:

1. Assess the needs for reproductive and child health at PHC level and undertake area-specific micro
planning.

2. To provide need-based demand-driven, high quality, integrated reproductive and child health care.

The expected level of achievement by the terminal year of 2002 were:

1. Crude birth rate (CBR) 23/ 1000

2. Infant mortality rate (IMR) 50/1000
3. Total fertility rate (TFR) 2.6
4. Couple protection rate (CPR) 60 per cent
5. Neonatal mortality rate (NNMR) 35/ 1000
6. Maternal mortality rate (MMR) 3/1000.

Implementation of the FWP

The following were the main components of Family Welfare Program.
1. Maternal health
2. Child health
3. Population control/stabilization.
The following were the schemes and programs for implementation of national family welfare:
1. Reproductive and Child Health Program (RCH)
2. Janani Suraksha Yojana
3. Vandemataram Scheme
4. Safe Abortion Services
5. National Rural Health Mission (NRHM)
6. Integrated Child Development Services (ICDS)

REPRODUCTIVE AND CHILD HEALTH PROGRAM (RCH)

To control population growth and taking care of health of women and children, the government of
India launched the RCH program in October 1997 with the objective of providing quality, integrated
and sustainable primary health care services to women in the reproductive age group and children
with special focus on family planning and immunization.

Essential Components of RCH Program

1. Prevention and management of unwanted pregnancy

2. Services for mothers during pregnancy, childbirth and postpartum period

3. Child survival services for new-borns and infants

4. Management of reproductive tract infections (R11) and sexually transmitted diseases

5. Establishment of an effective referral system

6. Reproductive services for adolescent health

7. Health services including counselling on sexuality and family life.

Services included in the Program for Mother and Children

1. Essential care for all mothers and children
(a) Registration by 12th to 16th week of pregnancy
(b) At least three antenatal check-ups during pregnancy
(c) Tetanus toxoid immunization to all pregnant mothers
(d) One tablet of iron and folic acid tablet daily for 100 days (2 tablets daily for anaemic mother)
(e) De-worming with Albendazole or Mebendazole during 2nd or 3rd trimester in areas where
hookworm infestation is common

(f) Safe and clean delivery services

(g) Preparing women for exclusive breast feeding and timely weaning

(h) Postpartum care, including contraception advice and services.

2. Early detection of complications

(a) Clinical examination to detect anaemia
(b) Referral and transportation to the nearest hospital of women with hemorrhage or complications
(c) Referral of all women identified as having pregnancy induced hypertension (BP > 140/90 mm Hg
and weight gain > 3 kg/month)
(d) Referral of all women who develop signs of infection following delivery or abortion
(e) Transfer of women in labor for more than 12 hours to the nearest hospital with facilities for
caesarean delivery.
3. Emergency care to those who need it
(a) Early identification of obstetric emergencies
(b) Initial management of emergencies and transfer to referral hospital without delay using the fastest
available mode of transport.
4. Care to women in the reproductive age group
(a) Counselling the women about Optimal timing and spacing of birth Small family norm Use and
choice of contraceptives Prevention of sexually transmitted diseases and reproductive tract infections
Importance of girl child.
(b) Information on availability of: Medical termination of pregnancy(MTP)services IUCD and
sterilization services
(c) Family planning services: Condom distribution Oral contraceptive dispensing IUCD services
(d) Recognition and referral of clients with sexually transmitted diseases and reproductive tract
infections.
5. Provision of clean and safe delivery practices at the community level
(a) Deliveries by trained personnel
(b) Provision of disposable delivery kits for deliveries
(c) Promotion of institutional deliveries
(d) Early identification and referral of high-risk cases

6. Newborn care
(a) Weighing all new-borns at birth. Normal weight 2500 to 2800 gm. Referral of new-borns
weighing < 2000 gm
(b) Resuscitation of asphyxiated new-borns using mucus sucker or breathing as required.
(c) Prevention of hypothermia
(d) Breastfeeding within one hour of birth
(e) Referral of new-borns who show signs of illness
(f) Education of mother on newborn care and feeding
7. Immunization Infants
(a) BCG one dose at birth
(b) DPT: three doses, beginning at 6th week at monthly interval
(c) Polio: First dose at birth for all institutional deliveries and 3 doses at one-month interval
(d) Measles: one dose at completion of 9 months (e) Vitamin A: First dose of 100,000 IU along with
measles vaccination.
Children 1 to 3 years
(a) DPT
(b) Oral polio vaccine booster dose at 16th to 18th month
(c) Vitamin A 2nd dose 200,000 IU at 16th to 18th month 3rd to 5th doses 200,000 IU each at 6
monthly intervals
Children 3 to 5 years
(a) Iron and folic acid (tablet) for children with signs of anaemia
(b) Treatment for worm infestation with Albendazole or Mebendazole.
8. Prevention of deaths due to diarrheal diseases
(a) Correct management
(b) Teaching mothers to increase body fluid with ORS (Oral rehydration solution), and normal
feeding
9. Prevention of deaths due to pneumonia
(a) Correct management of all cases of acute respiratory infections
(b) Referral of children with severe pneumonia or severe illness

THE REPRODUCTIVE AND CHILD HEALTH PHASE-II PROGRAMME

RCH phase II programme was started on 1 April, 2005 with an aim to reduce maternal and child
morbidity and mortality with emphasis on rural health care.

THE MAJOR STRATEGIES UNDER THE RCH PHASE II

1. Essential Obstetric Care

(i) Institutional delivery
(ii) Skilled attendance at delivery
(iii) Permitting auxiliary nurse midwives (ANMs) to use life-saving drugs and to carry out certain
emergency interventions.

2. Emergency Obstetric Care

(i) Operationalizing first referral units (FRUs) with skilled attendance at birth. The
minimum services to be provided by a fully functional FRU are:
(a) 24-hour delivery services, including normal and assisted deliveries

(b) Emergency obstetric care, including surgical interventions like caesarean sections.

(c) Newborn care

(d) Emergency care of sick children.

(e) Full range of family planning services including laparoscopic sterilization services.

(f) Safe abortion services using medical method of abortion upto 7 weeks using Mifepristone and
Misoprostol and manual vacuum aspiration for surgical abortion.

Comprehensive and safe abortion services are provided at public health facilities including 24 x 7
PHCs/ FRUs (SDHs/DHs/CHCs) including the delivery points. Supply of Nishay pregnancy
detection kits to sub centre for early detection kits to sub centre for early detection of pregnancy is
undertaken.
Nishchay-pregnancy Kit detection
 To detect pregnancy at the earliest.
 To save lives lost to unsafe abortion practices.
 Available at the sub-centre level and with ASHA.
Capacity Building of medical officers is carried out routinely in safe MTP techniques. ANMs.
ASHAs and other field functionaries are trained to provide confidential counselling for MTP and
promote post-abortion contraception.
Routine orientation and 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 is undertaken.
(g) Treatment of sexually transmitted infections (S'I'I)/ reproductive tract infections (RTI).

(h) Blood storage facility

(i) Essential laboratory services

(j) Referral (transport) services

(ii) Operationalizing peripheral health centres (PHCs) and community health centres
(CHCs) for round-the-clock delivery services.
3. Strengthening referral system by involving local self-help groups, non-government
organizations (NGOs) and women groups.
Village Health and Nutrition Day: Organizing of village Health and nutrition Day (VHNDs) at
anganwadi centre at least once every month to provide ante natal/post-partum planning and nutrition
are the part of various services being provided during VHNDs.
Newer Interventions
Screening of gestational Diabetes mellitus, screening for hypothyroidism for high risk group during
pregnancy. De-worming during pregnancy. Medical Methods of Abortion, birth companion during
delivery, Maternal Near Miss programme and Technical and operational guidelines for screening for
Syphilis during pregnancy are newer initiatives to improve Maternal Health services.

NEW INITIATIVES

1. Training of MBBS doctors in life-saving anaesthetic skills for emergency obstetric care.
Government of India is also introducing training of MBBS doctors in obstetric management skills.
Federation of Obstetric and Gynaecological Society of India (FOGSI) has prepared a training plan
for 16 weeks in all obstetric management skills, including caesarean section operation.
2. Setting up of blood storage centres at FRUs according to Government of India guidelines.
3. provision of RTI/STI services under NHM (national Health Mission), provision of STI/RTI care
services is very important strategy to prevent HIV transmission a very important strategy to prevent
HIV transmission and promote sexual and reproductive health under the National AIDS Control
Program (NACP IV) 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 IV. Services are being provided to all FRUs, CHCs, and at 24 x 7 PHCs through
various kits of different colors for different STIs.

JANANI SURAKSHA YOJNA (JSY), April 2005

1t was started to reduce maternal and infant mortality through encouraging delivery at health
institutions and focussing at institutional care among women in below poverty line families.
Features of Janani Suraksha Yojana
(i) JSY is 100% centrally sponsored scheme
(ii) Under National Rural Health Mission, it integrates the benefit of cash assistance to mothers
for institutional deliveries. The Accredited Social Health Activist (ASHA) works as a link
health worker between the women and government.
During the year 2006-2008, about 28.11 lakh pregnant women benefited from the scheme, out of
which 18.72 lakhs had institutional deliveries.
JANANI SHISHU SURAKSHA KARYAKRAM (JSSK)
Government of India has launched Janani Shishu Suraksha Karyakaram (JSSK) on 1st June 2011,
which entitles all pregnant women delivering in public health institution to absolutely free and no
expense delivery including caesarean section.
Pregnant women delivering in public health institutions to absolutely free and no expense delivery
including Caesarean section.

The initiative stipulates free drugs, diagnostics, blood and diet, besides free transport from home to
institution. between facilities in case of a referral and drop back home.

Similar entitlements have been put in place for all sick new-borns accessing public health institutions
for treatment all 30 days after birth. In 2013 this has been expanded to Sick infants and antenatal and
postnatal complications.

The following are the Free Entitlements for pregnant women:

- Free and cashless delivery

- Free caesarean section

- Free drugs and consumables

- Free diagnostics

- Free diet during stay in the health institutions

- Free provision of blood

- Exemption from user charges

- Free transport from home to health institutions

- Free transport between facilities in case of referral

- Free drop back from Institutions to home after 48 hrs stay

PRADHAM MANTRI SURAKSHIT MATRITVA ABHIYAN (PMSMA)

Carrying forward the vision of our Hon’ble Prime Minister, the Pradhan Mantri Surakshit Matritva
Abhiyan was launched in 2016 to ensure quality antenatal care to pregnant women in the country on
the 9th of every months. Package of services: 0 Routine antenatal check-up ' Diagnostic services 0
Identification and management of high risk pregnancy ' Counselling for nutrition, family planning,
birth preparedness, newborn and postnatal care ' Other-communication for behavioural change health
system strengthening for providing quality services. Referral transport.

MAA (Mother’s Absolute Affection)

MAA is a countrywide intensified breast-feeding promotion campaign targeting

i) All states and union territories

ii) Around 3.9 crore pregnant and lactating mothers

iii) 8.8 lakh ASHAs

iv) 1.51akhs sub-centres

v) 17,000 Birthing Facilities/Delivery Points

LaQshya
In order to further accelerate our decline in maternal and newborn mortality in the coming years,
Health Ministry recently launched ‘LaQshya Labour room Quality Improvement lnitiative’. LaQshya
program is a focused and targeted approach to strengthen key processes related t0 the labor rooms
and maternity operation theatres Which aims at improving quality of care around birth and Ensuring
Respectful Maternity Care (RMC). Launched on November 2017 by Ministry of Health and Family
Welfare, Govt. of India.

1. To reduce maternal and newborn mortality and morbidity due to API-I (Antepartum
Hemorrhage), PPH (Postpartum Hemorrhage), Retained placenta, Preterm labor, Preeclampsia and
Eclampsia, Obstructed labor, Puerperal sepsis, Newborn asphyxia, and Sepsis, etc.

2. The improve Quality of care

(i) During the delivery

(ii) Stabilization of complications
(iii)Enable an effective two-way follow-up system
(iv) Immediate post-partum care
(v) Ensure timely referrals

3. To enhance satisfaction of beneficiaries visiting the health facilities and provide Respectful
Maternity Care (RMC) to all pregnant women attending the public health facility

Quality Improvement (Q1) Cycles: The Fulcrum of LaQshya: The initiative prioritizes local
problem solving thereby ensuring ownership and accountability at the facility level through
formation of Quality Circles and Quality Teams at the intervention facilities. QI methodologies
(Plan-Do-Check-Act [PDCA] cycle) will be used to drive and sustain change through 6 defined QI
cycles.

1. Real-time Partograph generation, usage of safe birth and surgical safety check-list and
strengthening documentation practices for generating robust data for driving improvement

2. Presence of birth companion during delivery, Respectful Maternity Care and enhancement of
patients’ satisfaction

3. Assessment, triage and timely management of complications including strengthening of referral

protocols

4. Management of Labor as per protocols including management of Third Stage of Labor (AMTSL)
and rational use of oxytocin.
5. Essential and emergency care of newborn and pre-term babies including management of birth
asphyxia, timely initiation of breast feeding as well as Kangaroo Mother Care (KMC) for pre-term
newborn.

6.Infetion Prevention including Biomedical Waste Management

The Quality Circles will work on the selected themes and improve processes using methodologies.

Labor Room Quality Circle:

- Training
- IT (Information technology) Tools
- HR (Human resource)
- Quality Tools

VANDEMATARAM SCHEME

Vandemataram scheme is a voluntary scheme wherein the private doctors can volunteer themselves
for providing safe motherhood services. The enrolled doctors will display ’Vandemataram logo’ at
their clinic. Iron and folic acid tablets, oral pills, TT injections, etc., will be provided by the District
Medical Officers for free distribution to beneficiaries. The cases needing special care and treatment
can be referred to the government hospitals, who have been advised to take due care of the patients
coming with Vandemataram cards.

NATIONAL RURAL HEALTH MISSION (NRHM, 2005-12)

NRHM was started on 12 April 2005 by Government of India to deliver health services for
‘underprivileged' as a strategy for ’Health For All’. The objectives are:

1. To provide integrated comprehensive primary health care services.

2. For horizontal integration of vertical national health programs.

3. To cover all the villages in 18 states through, approximately, 2.5 lakh village-based “Accredited
Social Health Activists (ASHA)”.

4. NRHM has started with the activities of selection and training of ASHA.

The Goals to be Achieved by NRHM

A. At national level

1. Infant mortality rate (IMR) to be lowered to 30/ 1000 by 2012.

2. Maternal mortality rate (MMR) to be lowered to 100/ 100,000 live births by 2012

3. Total fertility rate (TFR) to be 2.1 by 2012

4. Sex ratio (0-6 years) to be 935 by 2012

5. Increasing utilization of FRUs-bed occupancy by referred cases from less than 20% to over
75%.

6. Reduction of mortality rates of Malaria, Filaria, Dengue, Kala-azar and Japanese

encephalitis

7. To reduce prevalence rates of leprosy and tuberculosis

8. Upgrading community health centres to Indian Public Health standards FPS”

B. At community levels

1. To avail trained community level workers at village level with a drug kit for general ailments

2. Provision of immunization, antenatal and postnatal check-ups and services related to maternal
and child health including nutrition at anganwadi level

3. Availing of generic drugs for common ailments at sub-centres level

4. To provide good hospital care through assured availability of doctors, drugs and quality
services at PHC and CHC level

5. To provide universal immunization

6. To improve facilities for institutional deliveries

7. Improve outreach services through mobile medical units at district level

 8. Provision of household toilets
Plan of Implementation of NRHM
Implementation of the NRHM program will be through ASHAs and ANMs.

Selection of ASHA

ASHA must be a resident of the village-a woman (married/widowed/divorced) preferably in the age
group of 25-45 with formal education up to eight class, having communication skills and leadership
qualities. There should be one ASHA for 1,000 population or one ASHA per habitation in tribal,
hilly and desert areas. The selected ASHAs will be trained to carry out specific responsibilities.

Roles and Responsibilities of ASHA

The ASHA works as a health activist in the community to carry out the following responsibilities:

1. To create awareness and provide information on health determinants like nutrition, basic sanitation
and hygiene practices, healthy living and the need for utilization of existing health and family
welfare services.

2. To counsel women on birth preparedness, safe delivery, breastfeeding, complementary feeding,

immunization, contraception and prevention of common infections like reproductive tract infections
and sexually transmitted infections.
3. To mobilize community in accessing health related services available at the anganwadi, sub-
centres and primary health centres such as immunization, antenatal check-up, postnatal check-up,
supplementary nutrition, sanitation and other services which are provided by the government

4. To identify women in families below poverty line (BPL) as beneficiaries of the scheme (NRHM)
and assist them to obtain BPL registration

5. To ensure that the Janani Suraksha Yojana (ISY) card is filled up at least 16-20 weeks prior to
delivery.

6. To work with the village health and sanitation committee of the Gram Panchayat to develop
comprehensive village health plan.

7. To arrange escort or accompany pregnant women and children requiring treatment or admission to
the nearest pre-identified health facility (sub-centres or PHC)

8. Provide primary medical care for minor ailments such as fever, diarrhoea and first aid for minor
injuries

9. Be a provider of 'directly observed treatment short course (DOTS) under National Tuberculosis
Control Program

10. Will act as a direct depot holder for essential provisions like oral rehydration solution (0R5), iron
and folic acid tablets, chloroquine, disposable delivery kits, oral pills and condoms and keep a
medicine kit with Ayush and allopathic formulations recommended by the technical/expert advisory
group of the government
11. Ensure registration of births and deaths in her village, any unusual health problems or disease
outbreaks in the community

12. Promote construction of household toilets under total sanitation campaign.

Co-operation and Integration with ANMs

The auxiliary nurse midwife will guide ASHA in performing her functions through various activities
as:

1. To hold weekly or fortnightly meetings to discuss various activities

2. To act as resource person for training of ASHA

3. To guide ASHA regarding arrangement for outreach programs

4. To participate and guide ASHA in organizing health days in anganwadi centre.

5. To utilize ASHA to motivate pregnant women to go to the sub-centre for check-ups, take full
course of iron and folic acid tablets and tetanus toxoid injections. The ANMs inform ASHA about
date, time and place for initial and periodic training schedule and also ensure that ASHA gets the
compensation for her performance and TA/DA to attend training.
NRHM Extended (NRIW [National Rural Health Mission] + NUHM [National Urban Health
Mission] = NHM [National Health Mission) ASHA (Accredited Social Health Activist)

ASHA One of the key components

To provide every village in the country with a trained female community health activist (ASHA) or
Accredited Social Health Activist. Selected from the village itself and accountable to it, the ASHA
will be trained to work as an interface between the community and the public health system.
Following are the key components of ASHA:

i) ASHA must primarily be a woman resident of the village married/ widowed/divorced, preferably
in the age group of 25 to 45 years.

ii) She should be a literate woman with due preference in selection to those who are qualified upto
10 standard wherever they are interested and available in good numbers. This may be relaxed only if
no suitable person with this qualification is available.

iii) ASHA will be chosen through a rigorous process of selection involving various community
groups, self-help groups, Anganwadi Institutions, the Block Nodal officer, District Nodal officer, the
Village Health Committee and the Gram Sabha.

iv) Capacity building of ASHA is being seen as a continuous process. ASHA will have to undergo
series of training episodes to acquire the necessary knowledge, skills and confidence for performing
her spelled out roles.

v) The ASHAs will receive performance-based incentives for promoting universal immunization,
referral and escort service for Reproductive and Child Health (RCH) and other healthcare
programmes, and construction of household toilets.
Empowered with knowledge and a drug-kit to deliver first-contact healthcare, every ASHA is
expected to be a fountain head of community participation in public health programmes in her
Village.

vi) ASHA will be the first part of call for any health related demands of deprived sections of the
population, especially women and children, who find it difficult to access health services.

vii) ASHA will be a health activist in the community who will create awareness on health and its
social determinants and mobilise the community towards local health planning and increased
utilisation and accountability of the existing health services.

viii) She would be a promoter of good health practices and will also provide a minimum package of
curative care as appropriate and feasible for that level and make timely referrals.

ix) ASHA will provide information to the community on determinants of health such as nutrition,
basic sanitation and hygienic practices, healthy living and working conditions, information on
existing health services and the need for timely utilisation of health and family welfare services.

x) She will counsel women on birth preparedness, importance of safe delivery, breast-feeding and
complementary feeding, immunization, contraception and prevention of common infections
including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STDs) and care of the
young child.
xi) ASHA will mobilise the community and facilitate them in accessing health and health related
services available at the Anganwadi/sub-centre/primary health centres, such as immunisation, Ante
Natal Check-up (ANC), Post Natal Check-up supplementary nutrition, sanitation and other services
being provided by the government.
xii) She will act as a depot holder for essential provisions being made available to all habitations like
Oral Rehydration Therapy (0R5), Iron Folic Acid Tablet (IPA), chloroquine, Disposable Delivery
Kits (DDK), Oral Pills and Condoms, etc.

xiii) At the village level it is recognised that ASHA cannot function without adequate institutional
support. Women's committees (like self-help groups or women’s health committees), village Health
and Sanitation Committee of the Gram Panchayat, peripheral health workers especially ANMs and
Anganwadi workers and the trainers of ASHA and in-service periodic training would be a major
source of support of ASHA.

RMNCH+A (Reproductive, Maternal Newborn, Child and Adolescent Health)

The Government of India adopted the Reproductive, Maternal, New-born, Child and Adolescent
Health (RMNCH+A) framework in 2013 and it essentially looks to address the major causes of
mortality among women and children.

3 Year Action Agenda 2017-20

Launched on August 2017 by Niti Ayog

- Reprioritize goals

- Healthcare system in the country must prioritize public health

- Shift from being curative to preventive.

NATIONAL NUTRITIONAL ANEMIA PROPHYLAXIS PROGRAMME

(NNAPI)
Nutritional anaemia being a major health problem in India, especially in women and children, the
Government of India initiated the National Nutritional Anaemia Prophylaxis Program (NNAPP) in
1970 to provide 60 mg elemental iron and 500 mg of folic acid supplements per day to all pregnant
women, lactating women, family planning acceptor women and children 1 to 11 years old.

The Ministry of Health and Family Welfare, Government of India has now recommended intake of
100 mg of elemental iron with 500 mg of folic acid in the second half of pregnancy for a period of at
least 100 days.

TWELVE-BY-TWELVE INITIATIVE FOR ANAEMIA CONTROL

Twelve-by-twelve initiative for anaemia control was launched on 23 April 2007 in association with
World Health Organization (WHO), United Nations International Children Education Fund
(UNICEF), Federation of Obstetric and Gynaecological Societies of India (FOGSI) and the
Government of India to decrease the incidence of anaemia in adolescents in order to ensure healthy
parenthood. It aims to have Hb of 12 g/dL by age of 12 years (hence the name).

Specific objectives
1. To determine prevalence of anemia in children between 10 and 14 years of age.

2. To provide nutritional guidelines and treatment for anemic children.

3. To vaccinate all children against tetanus and all girls against rubella.
4. To deworm all children and treat malaria, if present.

Indradhanush Scheme

- Launched by The Ministry of Health and Family Welfare (Govt. of India)

- On December 25, 2014.

The Mission Indradhanush, depicting seven colours of the rainbow, aims-to cover all those children
by 2020 who are either unvaccinated, or are partially vaccinated against seven vaccine preventable
diseases which include

Diphtheria
Whooping cough (Pertussis)
Tetanus
Polio
Tuberculosis
Measles
Hepatitis B

Intensified Mission Indradhanush (IMI)

- To reach each and every child under two years of age and all those pregnant women who have been
left uncovered under routine immunization programme.

- Focus on improving immunization coverage in select districts and cities to ensure full
immunization to more than 90% by December 2018.
Menstrual hygiene scheme

(i) Pack of 6 sanitary napkins ’Freedays’

(ii) Rs 6 per pack

(iii) Available with ASHA worker

Revised Menstrual Hygiene Scheme

i) Rs 6 for a pack of six sanitary napkins by ASHA through door to door sale

ii) Out of sale proceeds, the ASHA gets an incentive amount

- Rs 1 per pack free pack of sanitary napkins per month
iii) Balance fund recouped (returned) to the state health society account to be utilised for
procurement in the following year.

Dakshta

To strengthen the competency of the providers of the labor room, including medical officers, staff
nurses and ANMs (Auxiliary nurse midwife) to perform evidence based practices as per the
established labor room protocols and standards.

Clinical update cum skills standardization training: The initiative will undertake a short customized
clinical update cum skills standardization training for the providers of the labor rooms. This will be a
three-day activity which will be conducted by designated trainers at identified training sites.

All providers of labor rooms, irrespective of their training status in the 21day in-service SBA
trainings, will be eligible for these trainings.

Weekly Iron Folic Acid Supplementation

- Launched in 2013
- School age children
- Community based
- Orientation of teachers and parents regarding health, nutrition, diet, etc.
- Health card and Hb estimation of all children
- Set of 8-10 slides on importance of anaemia prevention to be distributed to all schools
- Organize Painting, poster competition
- Incorporate a chapter on anaemia in 5th-8 h standard textbooks
- Deworming, Organize iron day
- Repeat Hb after 6 months Iron + Initiative
- Beneficiaries receive iron and folic acid supplementation irrespective of their Iron/Hb status
Adolescent friendly health clinics
 PHC (primary health centre)- weekly by ANM (Auxiliary Nurse Midwife)/ MO (Medical
Officer)
 CHC (Community Health Centre)/DISTRICT – daily
 Nutrition
 Substance abuse
 Injury, violence, non-communicable diseases
 Mental Health
 Reproductive and Sexual health – ICTCs (integrated Counselling and testing centres)
 Gender sensitization
NATIONAL STRATEGIC PLAN FOR HIV/AIDS 2017-2024
Launched on December 1, 2017
“paving the way for an AIDS free INDIA”
PMTCT (prevention of mother to child transmission of HIV) – EPTCT (elimination of parent to
child transmission of HIV)
Targets:
 Targets of 95% of pregnant women for HIV and Syphillis
 Putting of 95% of estimated positive pregnant women on ART
 Achieving an MTCT rate of less than 5% by 2020
Elimination strategies for HIV and Syphilis
 Universal ANC Check-up
 Single prick for HIV and Syphilis
 Treat all who are syphilis positive
 Active case detection for partners with testing and treatment for HIV and Syphilis
 Available supply of commodities and drugs
 Collaboration with other agencies
 New detection and point of care tests
Package of services currently offered
The HIV testing and counselling (pre-test and post-test) in antenatal patients.
All HIV positive pregnant women, including those presenting in labor and breast-feeding
are to be initiated on lifelong triple ART, irrespective of CD$ count and WHO clinical
stage.
The recommendation duration of NVP (nevirapines) for the infants is a minimum of 6
weeks but can be extended to 12 weeks, if the duration of ART during pregnancy is <24
weeks.
MILLENNIUM DEVELOPMENT GOALS (MDG)
In September 2000, representatives from 189 countries met in New York to adopt the United
Nations Millennium Declaration in the area of development and poverty eradication. They are called
Millennium Development Goals (MDG) and are as follows in relation to obstetrics:
1. Reduce by two-thirds, between 1990 and 2015, the under-five mortality rate (Goal 4).
2. Reduce by three-quarters, between 1990 and 2015, the maternal mortality ratio (Goal 5).
3. Combat HIV/AIDS, malaria and other diseases
4. Skilled attendance at 90% births by 2015.
5. To reduce the infant mortality rate below 35 per 1000 live births by 2015.
6. Access to reproductive health services for all by 2015.
7. Other goals are gender quality, poverty reduction, education of girls and women.
The global strategy for Women’s Children and Adolescent’s Health (2016-2020) envisions a world
in which every woman, child and adolescent in every setting realizes their rights to physical and
mental health and well-being, has social and economic opportunities and is able to participate fully in
shaping prosperous and sustainable societies.

INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

ICDS scheme launched on 2nd October 1975 is one of the world’s largest and unique scheme for
early childhood development. It aims to break the vicious cycle of malnutrition, morbidity, reduced
learning capacity and mortality and to provide pre-school education.

1. Objectives

(a) To improve the nutritional and health status of children in the age-group 0-6 years;

(b) To lay the foundation for proper psychological, physical and social development of the child;

(c) To reduce the incidence of mortality, morbidity, malnutrition and school dropout;

(d) To achieve effective co-ordination of policy and implementation amongst the various
departments to promote child development

(e) To enhance the capability of the mother to look after the normal health and nutritional needs of
the child through proper nutrition and health education.

2. Services
(a) Supplementary feeding
(b) Immunization
(c) Health check-up
(d) Referral services
(e) Pre-school non-formal education for 3-6-year-old
(f) Nutrition and health education.
(g) Micronutrient supplementation
(h) Nutrition, health awareness and skills development for adolescent girls
(i) Income generation schemes for women.
Supplementary nutrition service includes growth monitoring, prophylaxis against vitamin A
deficiency and control of nutritional anaemia in children. All families in the community are surveyed
to identify children below the age of six, pregnant and nursing mothers. They are given
supplementary nutritional support for 300 days in a year. The program aims to bridge the caloric gap
between the national recommended and average intake of children and women in low income and
disadvantaged groups.

Children below the age of three are weighed once a month and children below 3 to 6 are weighed
once in 4 months. Growth rate and nutritional status are assessed and malnourished children are
given supplementary feeding and referred to medical centres.

Pregnant women are immunized against tetanus to reduce maternal and neonatal mortality.
Vaccination of infants and children for six vaccine preventable diseases poliomyelitis, diphtheria,
pertussis, tetanus, tuberculosis and measles is provided.

Health check-ups are offered to children up to 6 years, expectant and nursing mothers. The services
are provided by anganwadi workers and primary health centre (PHC) staff and include weight
checking, immunization, management of malnutrition, treatment of diarrhoea, de-worming and
distribution of simple medicines. The education component of the ICDS program is implemented
through the 1.4 million anganwadi centres. The early learning helps in cumulative, life-long learning,
development and aims towards universalization of primary education. Providing children, the
necessary preparation for primary schooling, nutrition and health education are key elements of the
work of anganwadi workers. Capacity building of women in the age group of 15 to 45 years is a
long-term goal of the program.

The ICDS Team

The ICDS team comprises from below upwards the anganwadi workers, anganwadi helper,
supervisors, child development project officers (CDPOs) and district program officers (DPOs).
Anganwadi workers are women selected from the local communities and act as community-based
front line workers of the ICDS program. The health teams include medical officers, auxiliary nurse
midwives (ANMs) and accredited social health activists (ASHAs) as functionaries of ICDS to
provide different services.

SAFE MOTHERHOOD INITIATIVE (SMI)

Considering the high rates of maternal deaths prevailing in developing countries of the world, WHO
launched ’Safe Motherhood Initiative’ (SMI) at a conference in Nairobi (Kenya) in 1987. The global
objective was aimed at reduction of maternal deaths by at least half by 2000 AD. This deadline was
then extended to 2010. It was proposed to achieve this objective by enhancing the quality and safety
of the lives of girl children and women through a combination of health and non-health strategies.
Maternal and child health promotion is one of the key commitments in the WHO constitution.
Strategies to Reduce Maternal Mortality and Achieve Safe Motherhood

1. Improve the status of women through education, health, career opportunities and vocational
training to enable them to achieve economic independence and become equal partners in nation
building.

2. Reduce high fertility through family planning.

3. Upgrade tertiary care hospitals and district hospitals to contemporary acceptable levels of
healthcare. Make transfusion services more easily accessible through networking of blood banks.

4. Improve obstetric services by making antenatal care more easily accessible, encourage supervised
institutional deliveries or home delivery under qualified supervision for low-risk cases. Strengthen
referral systems and transport facilities to ensure timely transfer of high-risk patients.

5. Improve standard of care for women in labor.

6. Ensure easy accessibility of medical termination of pregnancy (MTP) services.

7. Maintain appropriate training of health personnel to deal with obstetric emergencies and to be
equipped to undertake essential obstetric functions in primary healthcare centers and first referral
units (FRUs).

8. Utilize services of media (television, radio, news media) to promote women's health awareness
amongst the public. From time to time the Government of India started many health programs to
improve maternal and child health.
SUSTAINABLE DEVELOPMENT GOAL 3
By 2030
 To decrease global MMR < 70/100,000 live births
 To decrease (neonatal mortality rate) NMR < 12/1,000 live births, under-5 mortalities <
25/1,000 live births.
 Universal access to sexual and reproductive health care services + family planning,
information, education, integration of reproductive health into national strategies and
programmes.
 Universal health coverage – financial risk protection, access to safe, effective, quality and
affordable essential medicines and vaccines for all.
SUMMARY AND CONCLUSION
Safe motherhood Initiative (SMI) was started by WHO in 1987 to reduce maternal and deaths and to
promote maternal and child health. Various strategies to reduce maternal mortality and to achieve
safe motherhood are by improving the status of women in society, reducing fertility through use of
family planning and MTP services, improving referring and referral units, easy access to obetetrics
services with improved standard of care in labor. Various intervention and programmes have meen
made to prevent maternal deaths are promotion of family welfare services, dietary supplementation
and prophylaxis for anaemia, antenatal care and hospital deliveries, improvement of health care
facilities and training of healthcare workers.
BIBLIOGRAPHY
 Sharma JB, Textbook of Obstetrics, Avichal publishing Company, 2nd edition, page no. 554-
564
 Basavanthappa BT, Community Health Nursing 1st Edition, 1998, Jaypee Brothers, Delhi,
Page no. 319-321.
 Park K., Essentials of Community Health Nursing, 4th Edition 2004, Banarasidas Bhanot
Publisher, 225-22