![Maternal and Child Health Indicators - WHO
• Maternal mortality ratio
• Under-five child mortality, with the proportion of newborn deaths
• Children under five who are stunted
• Proportion of demand for family planning satisfied (met need for contraception)
• Antenatal care coverage (at least four times during pregnancy)
• Antiretroviral (ARV) prophylaxis among HIV positive pregnant women,
antiretroviral therapy for [pregnant] women who are treatment-eligible
• Skilled attendant at birth
• Postnatal care for mothers and babies within two days of birth
• Exclusive breastfeeding for six months (0–5 months)
• Three doses of combined diphtheria-tetanus pertussis (DTP3) immunization coverage (12–23 months)
• Antibiotic treatment for suspected pneumonia](https://image.slidesharecdn.com/socialobstetricsandgynaecology-240304013052-1e86e305/85/Social-Obstetrics-and-Gynaecology-for-doctors-3-320.jpg)
Social Obstetrics and Gynaecology for doctors
- 3. Maternal and Child Health Indicators - WHO • Maternal mortality ratio • Under-five child mortality, with the proportion of newborn deaths • Children under five who are stunted • Proportion of demand for family planning satisfied (met need for contraception) • Antenatal care coverage (at least four times during pregnancy) • Antiretroviral (ARV) prophylaxis among HIV positive pregnant women, antiretroviral therapy for [pregnant] women who are treatment-eligible • Skilled attendant at birth • Postnatal care for mothers and babies within two days of birth • Exclusive breastfeeding for six months (0–5 months) • Three doses of combined diphtheria-tetanus pertussis (DTP3) immunization coverage (12–23 months) • Antibiotic treatment for suspected pneumonia
- 4. Maternal Mortality • Maternal death: • During pregnancy, childbirth or within 42 days of delivery regardless of duration or site of pregnancy • From any cause related to or aggravated by pregnancy or its management • Not from accidental or incidental causes • Could be direct (75%) or indirect (25%) • Maternal mortality Rate • Number of maternal deaths in a given period per 100,000 women of reproductive age • Maternal mortality Ratio • Number of maternal deaths in a given period per 100,000 live births
- 5. The three delays model
- 6. Globally • Safe Motherhood Initiative - 1987 • Antenatal, intrapartum and postnatal care • Family planning • Post abortion care • STI and HIV control
- 7. Milestones in MCH in India • 1880 - Establishment of Training of Dais in Amritsar • 1902 - 1st Midwifery Act to Promote Safe Delivery • 1930 - Setting Up Of Advisory Committee on Maternal Mortality. • 1946 -Bhore Committee Recommendation on Comprehensive and 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 and Safe Motherhood Programme • 1997 - RCH Programme Phase‐1 (15.10. 1997) • 2005 - RCH Programme Phase‐2 (01‐04‐2005) • 2013 - RMNCH + A
- 8. RCH - I • Family planning programme • CSSM • Prevention and management of RTI/STI • Adolescent health care • To bring down the birth rate below 21 per 1000 population • To reduce the infant mortality rate below 60 per 1000 live birth • To bring down the maternal mortality rate <400/1,00,000 lakh • 80% institutional delivery, 100% antenatal care and 100% immunization of children
- 9. RCH - II • Objectives: • Reduction of Maternal Morbidity and Mortality • Reduction of Infant Morbidity & Mortality • Reduction of Under 5 Morbidity a nd Mortality • Promotion of Adolescent Health • Control of RTIs and STIs • Initiatives: • Training of PHC doctors in life savin ganesthetic skills for emergency obstetric care • Setting up of blood storage centers at FRUs • Janani Suraksha Yojana (JSY) • Vande Mataram Scheme (VMS) • Safe abortion services • Integrated Management of Neonatal & Childhood illnesses
- 10. RMNCH+A • Launched in February 2013 • To influence the key interventions for reducing maternal and child morbidity and mortality • Encompasses all interventions aimed at reproductive, maternal, newborn, child, and adolescent health under a broad umbrella, lifecycle approach • Provides a strong platform for delivery of services across the entire continuum of care, ranging from community to various level of health care system.
- 11. “Plus” focuses on: • Inclusion of adolescence as a distinct life stage • Linking MCH to reproductive health and other components like family planning, adolescent health, HIV, gender, and preconception and prenatal diagnostic techniques. • Linking home/community-based services to facility-based services. • Ensuring linkages, referrals, and counter-referrals between and among various levels of health care system to create a continuous care pathway
- 12. Approach • Health systems strengthening (HSS) - infrastructure, human resources, supply chain management, referral transport measures • Prioritization of high-impact interventions • Increasing effectiveness of investments by prioritizing geographical areas • Integrated monitoring and accountability - good governance, use of available data sets, community involvement, and steps to address grievance • Broad-based collaboration and partnerships
- 13. Maternal health
- 14. Maternal health indicators: Sr.No Indicator NFH S 3 NFH S 4 1 Mothers who had antenatal check-up in the first trimester (%) 43.9 58.6 2 Mothers who had at least 4 antenatal care visits (%) 37.0 51.2 3 Mothers who had full Antenatal care(%) 11.6 21 4 Mothers who received postnatal care from a doctor/nurse/LHV/ANM/midwife/otherhealth personnel within 2 days of delivery (%) 34.6 62.4 5 Institutional births (%) 38.7 78.9
- 15. Quality Service provision • Quality Ante Natal care: • At least 4 ANCs (early registration + first ANC in first trimester) • ANC Package includes physical examinations, investigations, T.T/Td immunization, IFA tablets & Calcium (6 months during Antenatal period & 6 months during postnatal period) and counselling for nutrition • Early detection of high-risk pregnancies, follow up and management • Essential Obstetric Care during Delivery : • Free institutional delivery at govt health facilities, to reduce maternal &neonatal morbidity and mortality. • 24 X 7 PHCs services, Skilled Attendance at Birth training. • Referral services at both Community and Institutional level • Assured referral systems to transport pregnant mothers and sick Infants, including public, private partnership models.
- 16. • Post natal care for Mother and New born: • Within first 24 hours of delivery and subsequent home visits on 3rd, 7th, 14th and 42nd day • Provision of Emergency Obstetric and Neonatal Care at FRUs: • Operationalizing all FRUs - manpower, blood storage units and referral linkages etc. • Availability of trained manpower (Skill Based Training for health care providers) is linked with operationalization of FRUs. The following key skill based training programs are being implemented: • 18 Weeks Training Programme of MBBS Doctors in Life Saving Anaesthesia Skills (LSAS) for Emergency Obstetric Care. • 16 weeks Training programme of MBBS Doctors in Obstetric Management Skills including C- Section, in collaboration with Federation of Obstetric and Gynaecological Society of India.(EmOC) • 10 days Training Programme in Basic Emergency Obstetric Care for Medical Officers (BEmOC) • 3 weeks Training Programme for ANMs/SNs/LHVs as Skilled Birth Attendants (SBA) Referral • Skills Labs (Daksh training) – National and State level
- 17. Training • Skilled Attendance at Birth • Staff Nurses and ANMs are permitted/trained to give certain injections and also perform certain interventions under specific emergency situations • Manage and handle some common obstetric emergencies at the time of birth • DAKSHATA initiative • Goal: To improve the quality of maternal and newborn care during the intra- and immediate postpartum period, through providers who are competent and confident • Ensure adherence to the highest impact clinical practices during the intra- and immediate postpartum period, major focus being in the labour room and postpartum ward. • The package provides the complete set of resources to assist the States in planning and implementation. Operational guidelines, learning resource package, assessment tools, planning and budgeting tools are included in the package.
- 18. Strategies and interventions • Flagship programs • Janani Suraksha Yojana (JSY) • Janani Shishu Suraksha Karyakram (JSSK) • Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) • LaQshya • Other programs • Comprehensive abortion care services • RTI/STI services • Village health and nutrition day • Newer interventions – Nurse practitioners and Midwifery
- 19. Janani Suraksha Yojana • Launched in April 2005 to promote institutional delivery • Centrally sponsored scheme, integrates cash assistance with delivery and post-delivery care • Accredited Social Health Activist (ASHA) as an effective link between the government and pregnant women • Cash entitlement for different categories of mothers: Category Rural area Total Urban area Total Mother’s package ASHA’s package* Mother’s package ASHA’s package** (Amount in Rs.) LPS 1400 600 2000 1000 400 1400 HPS 700 600 1300 600 400 1000
- 20. Janani Shishu Suraksha Karyakram • Launched in June 2011 to eliminate out-of-pocket expenses for pregnant women and sick infants • In 2014 extended to all antenatal & post-natal complications of pregnancy • Entitles all pregnant women delivering in public health institutions to absolutely free and no expense delivery, including caesarean section • Includes free drugs and consumables, free diagnostics, free blood wherever required, and free diet for 3 days during normal delivery and 7 days for C- section • Also provides for 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 newborns and infants (up to one year of age) accessing public health institutions for treatment.
- 21. Pradhan Mantri Surakshit Matritva Abhiyan • Launched in 2016, to provide fixed-day assured, comprehensive and quality antenatal care universally to all pregnant women on the 9th every month • Special services - OBGY specialists/ Radiologist/ Physicians at government health facilities • Identification and follow-up of high risk pregnancies • Red stickers are added on to the JSSK cards • Specialists working in the private sector are encouraged to volunteer for the campaign • “I Pledge for 9” achiever’s awards – incentive for individual and team efforts
- 22. LaQshya • Launched in December 2017 as a quality improvement initiative in labour room & maternity OT • Background - Increase in institutional deliveries without proportionate decrease in maternal and newborn mortality • Objectives: • Reduce maternal and newborn morbidity and mortality • Improve quality of care during delivery and immediate post-partum period • Enhance satisfaction of beneficiaries, positive birthing experience and provide Respectful Maternity Care (RMC) to all pregnant women attending public health facilities
- 23. • Key Features: • Multi-pronged strategy: Infrastructure upgradation, ensuring availability of essential equipment, providing adequate Human Resources, capacity building of health care workers and improving quality processes in labour room. • Skill-based training like Dakshata, strengthen critical care in Obstetrics • Incentives: • Every facility achieving 70% score on NQAS will be certified as LaQshya certified facility. • Facilities achieving NQAS certification and 80% satisfied beneficiaries • Rs. 6 lakhs, Rs.3 lakhs and Rs.2 lakhs for Medical College Hospital, District Hospital and FRUs respectively.
- 24. • Strategies: • Reorganizing Labour Room & Maternity Operation Theatre layout • Dedicated obstetric HDUs and Obstetric ICU at all Government Medical College Hospitals, District Hospitals • Ensuring strict adherence to clinical protocols for management and stabilization of the complications before referral to higher centers • Continued mentoring and hand holding support to improve skills • Regular MDSR, C-section audit and Referral audits • Collating best quality practices across States
- 25. Surakshit Matritva Ashwasan (SUMAN) • Launched in October 2019, integrates existing initiatives • Incorporates the WHO recommendations for a positive pregnancy experience (2019) • AIM • Assured, dignified and respectful delivery of quality healthcare services at no cost • Zero tolerance for denial of services to any woman and newborn visiting a public health facility • To end all preventable maternal and newborn deaths and morbidities and provide a positive birthing experience • Zero tolerance for any negligence • Respect for women’s autonomy, dignity, feelings and choices • 100% maternal death reporting and reviews • Grievance redressal and client feedback mechanisms • Awards to Champions, community engagement, intersectoral convergence
- 28. Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act • PNDT act – 1994 • Regulating and banning the practice of sex determination/selection and abortion using pre-natal techniques such as amniotic fluid and chorionic villi sampling • Ineffectiveness - amendment made in 2003 incorporated scan centres • Requirements: • Registration under Section (18) of the PC-PNDT Act. • Written consent of the pregnant woman and prohibition of communicating the sex of fetus under Section 5 of the Act. • Maintenance of records as provided under Section 29 of the Act – FORM F • Creating awareness among the public at large by placing the board of prohibition on sex determination
- 29. • Punishment in the form of up to 3 years imprisonment and up to Rs 10,000 fine, and on repeat offence up to 5 years imprisonment and up to Rs 50,000 fine. • The name of the registered practitioner would be removed from state council for 5 years if guilty and permanently if repeat offence is committed under section 23 of the act.
- 31. Rashtriya Kishor Swasthya Karyakram (RKSK) • Launched in January 2014 • Expands the scope of adolescent health programming in India - from being limited to sexual and reproductive health, to also include nutrition, injuries and violence (including gender based violence), non-communicable diseases, mental health and substance misuse • Health promotion approach - reaching adolescents in their own environment, such as in schools, families and communities • Adolescent Friendly Health Clinics • Peer Education Program • Weekly Iron Folic acid supplementation • Menstrual hygiene scheme
- 32. • WIFS • Administration of supervised Weekly Iron-folic Acid Supplements of 100mg elemental iron and 500ug Folic acid using a fixed day approach. • Screening of target groups for moderate/severe anaemia and referring these cases to an appropriate health facility. • Biannual de-worming (Albendazole 400mg), six months apart, for control of helminthic infestation. • Information and counselling for improving dietary intake and for taking actions for prevention of intestinal worm infestation. • MHS • To increase awareness among adolescent girls on Menstrual Hygiene • To increase access to and use of high quality sanitary napkins to adolescent girls in rural areas. • To ensure safe disposal of Sanitary Napkins in an environmentally friendly manner. • “Freedays” - Rs 6 for a pack of 6 napkins, distribution and education mediated through ASHA
- 33. Family planning
- 34. Strategies Policy Level Service Level Target free approach More emphasis on spacing methods Voluntary adoption of Family Planning Methods Assuring Quality of services Based on felt need of the community Expanding Contraceptive choices Children by choice and not chance
- 35. Methods provided by the government at different levels Spacing Methods Limiting Methods IUCD 380 A and Cu IUCD 375 Female Sterilization: Injectable Contraceptive MPA (Antara Programme) Laparoscopic Combined Oral Contraceptive (Mala-N) Minilap Centchroman (Chhaya) Male Sterilization: Progesterone-Only Pill (POP) No Scalpel Vasectomy Condoms (Nirodh) Conventional Vasectomy EMERGENCY CONTRACEPTION Emergency Contraceptive pills (Ezy pills)
- 36. Mission Pariwar Vikas • Providing more choices through newly introduced contraceptives : MPA (Antara Programme) and Ormeloxifene (Chhaya) • Emphasis on Spacing methods like IUCD, capitalise on increased institutional deliveries 🡪 PPIUCD • Strengthening community based distribution of contraceptives by involving ASHAs • Availability of Fixed Day Static Services at all facilities • Emphasis on minilap tubectomy services • At least one provider for IUCD, minilap and NSV to be available at various health facilities, Sub Centres with ANMs trained in IUD insertion • Quality Assurance Committees at state and district levels • Plan for accreditation of more private/ NGO facilities to increase the provider base • Increasing male participation and promoting Non scalpel vasectomy • Generation activities in the form of display of posters, billboards and other audio and video materials • Strong Political Will and Advocacy at the highest level, especially in states with high fertility rates
- 37. Tamil Nadu
- 38. Dr Muthulakshmi Maternity Benefit scheme • Enhanced financial assistance to poor pregnant mothers • Aims to provide optimal nutrition for pregnant and lactating women and compensates the wage loss during pregnancy • Eligibility: • > 19 yrs of age, all 5 installments for two deliveries only, higher order birth and migrant mothers will receive 1st and 5th installments on certain conditions • VHN/UHN should certify the economic status • Should register before 12 weeks
- 40. Amma Maternal Nutrition Kit
- 41. References • https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=794&lid= 168 • https://suman.nhp.gov.in/ • https://krishnagiri.nic.in/scheme/dr-muthulakshmi-maternity- benefit-scheme/