RCH PHASE-II Revised By Dr.I.Selvaraj,I.R.M.S B.Sc., M.B.B.S., (M.D COMMUNITY MEDICINE).,D.P.H.,D.I.H PGCH&FW (NIHFW, New Delhi)., M.I.P.H.A Sr.D.M.O (Selection Grade Officer)/ S.Rly (on Study Leave) INDIAN RAILWAY MEDICAL SERVICE

India is the second most populous country in the world. It has 2.4% world’s land area with 16.7% world population. Total population of India is million. Annual growth rate is 1.93% million Babies are born/per year. UP is most populous state in our country. 50% of the country’s population is in 5 states (UP. Maharashtra, Bihar, WB, & AP). It is expected that in 2045 it may touch million marks million People are living in urban slums in 607 cities/towns (10th five -year plan). Tribal people constitute 8.2% of the country’s total population. In India women (15-45yrs) and children (<15 yrs) constitute 60% of the total population in India. It is said that about 30 million women experience pregnancy, 27 million have a live birth (MOHFW, 2003). 100,000 maternal deaths and one million newborn deaths occur annually.

As on December 2002, the total number of allopathic doctors registered with the MCI was 605,800 giving a doctor-population ratio of 1:1800, which changes to 1:800 after accounting for registered practitioners of Indian System of Medicine and Homeopathy (ISM&H). About 74% of doctors live in urban areas, where only 28% of population resides. More than 80 percent of qualified medical doctors are in private practice and more than 1.25 million untrained, unqualified registered medical practitioners (RMPs) provide informal private healthcare mostly in villages & slums. It is estimated that around 7000 NGOs are involved in health related activities

MILES STONE IN MCH CARE 1880 – Establishment of Training of Dais in Amritstar st Midwifery Act to Promote Safe Delivery Setting Up Of Advisory Committee on Maternal Mortality 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 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 ( )

The first phase of the programme was started on 1997 with an aim to bring down the birth rate below 21 per 1000 population, to reduce the infant mortality rate below 60 per 1000 live birth and to bring down the maternal mortality rate <400/1,00,000lakh. 80% institutional delivery, 100% antenatal care and 100% immunization of children were other targeted aims of the RCH programme.

The 5 year RCH phase II is being launched in TamilNadu on 2005 with a vision to bring about outcomes as envisioned in the Millennium Development Goals, the National Population Policy 2000 (NPP 2000), the Tenth Plan, the National Health Policy 2002 and Vision 2020 India, minimizing the regional variations in the areas of RCH and population stabilization through an integrated, focused, participatory programme meeting the unmet needs of the target population, and provision of assured, equitable, responsive quality services.

Indicator Tenth Plan Goals ( ) RCH II Goals ( ) National Population Policy 2000 (by 2010) Millennium Development Goals (B y 2015) Population Growth 16.2% ( ) -- Infant Mortality Rate 45/100035/100030/1000- Under 5 Mortality Rate ---Reduce by 2/3rds from 1990 levels Maternal Mortality Ratio 200/100,000150/100,000100/100,0 00 Reduce by 3/4th from 1990 levels Total Fertility Rate Couple Protection Rate 65% Meet 100% needs -

OBJECTIVES OF RCH PHASE-II PROGRAMME: 1.Reduction of Maternal Morbidity And Mortality 2.Reduction of Infant Morbidity And Mortality 3.Reduction of Under 5 Morbidity And Mortality 4.Promotion of Adolescent Health 5.Control of Reproductive Tract Infections and Sexually Transmitted Infections.

Reproductive health can be defined as a state in which people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancy is successful in terms of maternal and infant survival and well being, and couples are able to have sexual relations free of the fear of pregnancy and of contracting diseases.

RCH PACKAGE OF SERVICES

MOTHERS: 1.All pregnancies to be registered by health workers. 2. Pregnant women must be given two doses of tetanus toxoid immunizations. 3. Pregnant women must be given iron folic acid tablets for prevention and treatment of anemia. 4. Pregnant women must be given three antenatal checkups, which include checking their blood pressure and ruling out complications. 5. Deliveries by trained personnel in safe and hygienic surroundings should be encouraged. 6. Institutional deliveries should be encouraged for women having complications. 7. Referrals should be made to first referral units for management of obstetric emergencies. 8. Three postnatal checkups should be given to mothers after the delivery. 9. Spacing of at least three years between children must be encouraged

CHILDREN 1.Essential newborn care like keeping the baby warm, checking the baby's weight and giving the baby mother's first milk is important. The premature babies or low birth weight babies need special care. Babies with any complications should be refereed to the nearest health center. 2. Exclusive breast-feeding must be encouraged for the first three months. Weaning or starting the baby on semisolid food should start in the fourth month. 3. BCG, DPT, Polio and Measles immunizations should be administered to every child meticulously to prevent death and disabilities. 4. Vitamin A prophylactic for children is necessary to prevent blindness. 5. Parents must be informed about oral rehydration therapy and correct management of diarrhea. The availability of ORS packets in the villages should be ensured. 6. Acute respiratory infection in children should be detected early. They can be treated by cotrimoxazole tablets. Acute cases should be refereed to health center. 7. Treatment of Anemia.

ELIGIBLE COUPLES 1.Promoting use of contraceptive methods among eligible couples is important to prevent unwanted pregnancies. Couples should be able to choose from various contraceptive methods including condoms, Oral pills, IUDs, male and female sterilization. 2. Safe services for medical termination of pregnancies should be encouraged for women desiring abortions.

OTHER NEW SERVICES 1. A large number of people suffer in silence due to reproductive tract infections (RTIs) and sexually transmitted diseases (STDs). RTIs and STDs can make people infertile. If a pregnant woman has RTIs or STDs, it can affect the health of her child. People suffering from such infections should be referred to the health center. 2. Adolescents are parents of tomorrow. It is important to prepare them for the future by counseling them on family life and reproductive health. This can be a sensitive topic, as it has not been addressed before. Therefore, the involvement of parents, Anganwadi workers, and Mahila Swasthya Sanghs should be ensured

POOR QUALITY OF MCH SERVICES Limited technical competence of service providers. Lack of public health expert (Diploma in Public Health, M.D Post graduate in Community Medicine) with epidemiological skills for micro level planning Non-availability of complementary inputs such as drugs and equipment Poor client - provider interaction due to poor communication skills of service providers and their deterrent attitude towards the clients. Low motivation levels of staff Staff absenteeism Faulty planning and management skills at the periphery Inflexible programme design Lack of political support to public health Financial constraints Over lapping of activities and wastages of resources in the implementation of RCH programme There is no vigilance checkup

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

NEW STRATEGY OF RCH PHASE  1. To constitute empowered action group 2. Training of dais 3. To conduct RCH camps & organize RCH out reach scheme 4. Gadchiroli model to take care of home based neonatal care 5. Kangaroo mother care to take care of low birth weight infants 6. Border district cluster strategy 7. Integrated management of childhood illness strategy to take care of sick newborns

8. Training of MBBS doctors in Life saving anesthetic skills for emergency obstetric care at FRUs. 9.Strengthening of core strategy of the existing PHCs and CHCs, and provision of bedded CHC per lakh population for improved curative care to a normative standard (Indian Public Health Standards defining personnel, equipment and management standards) 10.Janani Suraksha Yojna (National Maternity Benefit Scheme) is envisaged as a package of services, geared at reducing maternal mortality, neonatal mortality, and female feticide and gender disparity. 11. “Vandematram” scheme-launched on 9th Feb in all the districts of the country with the active collaboration of the professional bodies. The aim of the scheme is to reduce the maternal mortality and morbidity of the pregnant and expectant mothers by involving and utilizing the vast resources of specialists/trained workforce available in the private sector. 12.A new initiative in National Rural Health Mission ( ) is accountability. Every village/large habitat will have a female Accredited Social Health Activist (ASHA), accountable to the Panchayat. She will act as the interface between the community and the public healthcare system.

NEW INITIATIVES IN RCH PHASE-II MATERNAL HEALTH All Community health centers & 50% of the Primary health centers are to be made functional for providing 24hrs delivery services. Primary Health Centers are proposed to be taken up for improving access to Essential Obstetric and New Born Care services round the clock. 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. Improvement of the referral networking systems by establishing emergency helpline Regular conduct of blood donation camps for the continued availability of blood in the blood banks. Universalizing the concept of birth companionship during the process of labour in all health facilities conducting deliveries. Operationalisation of maternal death audit to address the issues that have led to maternal deaths

INFANT AND CHILD HEALTH Reduction of Neo-natal deaths, infant deaths and child deaths by providing continuous health care and strengthening of new-born care infrastructure facilities. Organizing counseling sessions for the mothers. Implementing integrated management of neonatal and childhood illness Operationalising infant death/stillbirth verbal autopsy. Addressing the issue of female infanticide and foeticide.

FAMILY WELFARE 1. Higher order births will be targeted for intensified intervention 2. Social marketing technique for condom, promotion of IUD insertions, familiarizing the concept of one-stop Family Welfare Centre. 3. Increasing access to safe abortion services by popularizing manual vacuum aspiration (MVA) technique. 4. Establishment of one-stop family welfare services at Comprehensive Emergency Obstetric and New Born Care (CEMONC) Centres. 5. Popularizing No Scalpel Vasectomy. 6. Availability of a wide range of contraceptive methods MCH and other services

7. Accessibility, complete and accurate information about contraceptive methods, including their health risks and benefits 8. Safe and affordable services, along with high quality supplies 9. Well-trained service providers with skills in inter- personal communication and counseling. 10. Appropriate follow-up care 11. Regular monitoring and evaluation of performance 12. A paradigm shift from individualized vertical interventions to a more holistic and integrated life cycle approach giving more focused attention to the reproductive health care.

OTHER INNOVATIVE REFORMS: 1. Improved drug procurement & supply systems to tackle the problem of inadequate and irregular supplies 2. Improved supply of cross-matched blood in first referral units thereby decreasing the inter-institutional transfers for transfusion 3. Regular conduct of blood donation camps for the continued availability of blood in the blood banks. 4. Systematic reporting and auditing of maternal & infant deaths 5. For monitoring purposes, standardized systematic reporting of services rendered at primary care level, using simple, manually completed, computer readable forms

6. Ensuring block and district level inter-sectoral coordination for ICDS 7. Improvement of the referral networking systems by establishing emergency help line 8. Each community health center should have one additional post of public health manager and public health nurse 9.A co-ordination committee of the professional medical associations viz. IPHA, IAPSM, &FOGSI to monitor the RCH programme 10.Strengthening of IEC activities. These activities should cover the following messages: Ideal age at marriage, Ideal age to have a child, Small family norm, Avoidance of higher order births, Spacing, Contraceptive acceptance, Importance of female literacy, Anaemia control, Monitoring the weight gain of mothers and growth monitoring of babies, Breast feeding and importance of colostrums, Diarrohoea management, Oral rehydration therapy, Eradication of female infanticide and foeticide, Upholding the image of girl child and women, safe delivery, Institutional delivery, Immunizations and nutrition. Propagation of messages through films, Video spots, dramas, Street plays and booklets have to be undertaken. Electronic media such as T.V. and radio have to be utilized. Audio-visual aids will be provided in medical institutions and publication of booklet on IEC activities.

PACKAGES OF SERVICES AT FRU Vacuum Extractions Administration of Anesthesia Blood Transfusion Caesarean Section Manual Removal of Placenta Carry out Suction Curettage for Incomplete Abortion Insert Intrauterine Devices Sterilization Operation

TYPES OF KIT FOR FIRST REFERAL UNIT 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

INDICATORS OF MONITORING &EVALUATION RCH-II PROGRAMME 1.The public health managers have to monitor the programme. 2.They have to evaluate the effectiveness of the programme with the following indicators.

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 % Sub centers 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 postnatal maternal morbidity % Baby breast-feeds 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/ST

Key Indicators Source Total Fertility Rate3.32 births per womenSRS 1997 Couple Protection Rate48%NFHS-2 ( ) Unmet need of family planning16 %NFHS-2 ( ) Under 5 Population10.7%Census of India, 2001 Females yr age Group22.2%Census of India, 2001 Female literacy rate (%)54.3%Census of India,2001 Average age at first marriage16.8 years for women age 20-49)NFHS-2 ( ) Average age at first Birth19.6 years for women age 25-29NFHS-2 ( ) Maternal Mortality Rate407 / 100,000 live birthsRGI, 1998 Under 5 Mortality Rate95 / 1000 live BirthsSRS 2000 Infant Mortality rate63 / 1000 live BirthsSRS, 2004 Neonatal mortality rate4 4/1000 live BirthsSRS 2000 Perinatal mortality rate40 /1000 BirthsSRS 2000 Still Birth Rate8/1000 BirthsSRS 2000 Home Deliveries65.4%NFHS-2 ( ) Deliveries by Skilled Birth Attendants42.3%NFHS-2 ( ) Percentage Received ANC care (at least 1 visit) 65.4 %NFHS-2 ( ) Percentage received at least 3 visits43.8 %NFHS-2 ( ) Received Tetanus Toxoid 2 or more doses 66.8 %NFHS-2 ( ) Received IFA for at least 3 months47.5 %NFHS-2 ( )

CONCLUSION: Public health experts should be an essential part of the executive management team and will have to play a key role in our country by identifying the major problems in the RCH programme such as the absence of links between communities, subcentres and referral facilities; shortages of equipment and trained staff at referral facility; and a lack of emergency transport to adequately meet the needs of pregnant women particularly for obstetrical emergencies. Allocation of resources should be linked to states performance as well as to population size. They have to identify the new indicators for performance, and allocation of resources based on the felt need of the on priority. Active participation of Community with involvement and support of women’s self help groups, village health nurse, anganwadi workers, asha activist etc., will be very effective in improving women accessibility to different components of RCH services and increasing sensitivity to women’s needs. The private sectors role in improving women’s health is very helpful. We have to find out a mechanism to involve them through appropriate rules &regulations to provide the RCH Phase-II programme to the community. World Health Day slogan 2005 “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. The World Health Day slogan 2006 “Working together for health” reflects the involvement of health care workers to provide quality health care services to the community. The fulfillment objective of Phase-II RCH programme is the joint effort of community and service providers.

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