maternal health nursing introduction unit

maternal health nursing, preconceptional care, MTP act, maternity benefit act, family planning incentives

1. MATERNAL HEALTH NURSING

2. INTRODUCTION Maternal health refers to the health of women during pregnancy, childbirth and the postnatal period. maternal health nursing involves the care of woman and family throughout the pregnancy & child birth and the health promotion & illness care for the children and families

3. midwife A midwife is a person who having been regularly admitted to a midwifery education,but recognized bythe country in which it is located, has successfully completed the prescribed course of studies in midwifery and has aquire the requisite to be registered and or legally licenced to practice midwifery

4. HISTORICAL REVIEW midwifery has an old history mentioned in old testament in 460 BC, Hippocrates organised training and supervised midwives Aristotle (384 - 322 BC), the father of embryology also descibed qualities for a midwife Soranus was the first one to specialise in obstetrics & gynaecology Leonardo da Vinci made anatomical drawings of gravid uterus

5. in 1513, first book on midwifery was printed in Germany Ambroise Pare (1510-1590) laid the foundations for modern obstetrics. he performed internal podalic version and sutured perineal lacerations. he founded school for midwives in Paris William Harvey described fetal circulation & placenta Chemberlain designed obstetric forceps Fielding ould described normal mechanism of labour and performed first episiotomy

6. in 1862, Florence Nightingale organised training school for midwives at King’s college Hospital in 1902, the first English midwives act was passed Munro Kerr in 1926 introduced the present technique of LSCS

7. In INDIA 1885: an association for medical aid by the women of India was established by Countess of Dufferin 1918: Lady Reading health school was started in Delhi, offering health visitor’s course 1921: Lady Chelmsford League was formed for developing maternal & child health services 1931: the Indian Redcross society established MCH bureau 1949: INC was constituted

8. In Kerala Ancient Times- Untrained Dais  1901-dais given Skill Training for 1 year  1939- JPHN Course of 1 ½ year duration started , later to 2year  1972- Bsc. Nursing started In Kerala At Govt.Hospital Trivandrum  2011- 1year Course of Independent Nurse Midwifery Practice/Training at Govt Hospital Trivandrum.

9. planned parenthood

10. preconception care Set of interventions that aims to identify & modify biomedical, behavioural & social risks to a woman’s health or pregnancy outcome through prevention & management. components Early detection & prevention of health risks Management high risks before conception Active management of fertility Creation of awareness among women about contraception

11. objectives Maximise the health of prospective parents and hence their babies Reduce perinatal mortality& morbidity Provide information to prospective parents to make informed choices & make them ready to be parents Evaluate need for genetic counselling Reduce unplanned pregnancies Inform about maternity services

12. Activities history collection physical examination determination of preexisting illness genetic counselling nutrition advises & lifestyle modifications contraception and planning pregnancy physical preparation of couple psychological preparation of the family financial planning preparatory classes for couple, sibling and significant others

13. maternal morbidity and mortality

14. Maternal morbidity Maternal morbidity is defined as “any condition that is attributed to or aggravated by pregnancy and childbirth which has a negative impact on the woman's wellbeing and/or functioning.”

15. maternal mortality The annual number of female deaths from any cause related to or aggravated by pregnancy or its management (excluding accidental or incidental causes) during pregnancy and childbirth or within 42 days of termination of pregnancy, irrespective of the duration and site of the pregnancy.

16. maternal mortality ratio The maternal mortality ratio (MMR) is defined as the number of maternal deaths during a given time period per 100,000 live births during the same time period. Maternal Mortality Ratio(MMR) of India for the period 2016-18,  as per the latest report of the national Sample Registration system (SRS) data is 113/100,000 live births

17. legislations related to maternity benefits

18. maternity benefit act 1961 • OBJECT: To regulate the employment of women in certain establishments for certain periods before and after childbirth and to provide for maternity benefits and certain otherbenefits. • APPLICABILITY: It extends to the whole of India and applies to i) every factory, mine, plantations, establishments for the exhibition of equestrain,acrobatic and other performances. to every shop or establishments defined under any law applicable to such establishments in a state in which persons are employed on any day of the preceding twelve months.

19. PROHIBITED PERIOD OF EMPLOYEMENT OR WORK: The employment of women, or work by women in any establishment during the six weeks immediately following the day of her delivery or her miscarriage (section-4). PAYMENT OF MATERNITY BENEFIT: Every women shall be entitled to, and her employer shall be liable for, the payment of maternity benefit at the rate of average daily wage for the period of her actual absence, and any period of her actual absence, and any period immediately following the date of delivery and including the actual day for her delivery (Section –5). In addition to the maternity benefit, every women shall also be entitled to receive a medical bonus of Rs.250/- if no prenatal confinement and post natal care is provided free of charge (section-8)

20. ELIGIBILITY FOR MATERNITY BENEFIT: A women shall be entitled to maternity benefit only if she has actually worked in an establishment of the employer for a period of not less then eighty days in the twelve months immediately proceeding the date of her expected delivery (section-5[2])

21. MAXIMUM PERIOD OF MATERNITY BENEFIT: Maximum twelve weeks of which not more then six weeks shall proceed the date of her expected delivery (section- 5[5]) • OTHER BENEFITS: Act also provides provisions for leave for miscarriage, leave for illness arising out of pregnancy or delivery, premature birth of child or miscarriage and nursing breaks for nursing the child until the child attained the age of 15 months • DISMISSAL, DEDUCTION WAGES, ETC: No employer shall discharge or dismiss a women for her absence form work in accordance with the provisions of this Act and no deduction shall be made from the normal; and usual daily wages of a women entitled to maternity benefits.

22. MATERNITY BENEFIT AMENDMENT ACT 2017 Amended certain terms included those women who use their egg to fertilise in a surrogate mother the leave days extended to 26 weeks, out of which 8 weeks can be taken just before delivery for women having 2 or more children, the leave days will be 12 weeks, of which not more than 6 weeks before delivery a woman who legally adopts a child below 3 months or a commissioning mother shall be entitled to maternity benefits for a period of 12 weeks from the date the child is handed over to the adopting mother or commissioning mother, as the case may be

23. in case, where the nature of work assigned to a woman is of such nature that she may work from home, the employer may allow her to do so after availing of the maternity benefit for such period and on such conditions as the employer and the woman may mutually agree every establishment having fifty or more employees shall have a facility of creche within such distance as may be prescribed, either separately or along with the common facility; provided that the employer shall allow 4 visits a day to the creche by the woman which shall also include the interval for rest allowed to her every establishment shall intimate in writng and electronically to every woman at the time of her initial appointment regarding every benefit available under the Act

24. the employees’ state insurance act maternity benefit: 24 weeks paid leave (6 weeks antenatal and 18 weeks postnatal) for 2 births expense of hospitalization

25. MTP ACT

26. objectives Aims to improve the maternal health scenario by preventing large number of unsafe abortions and consequent high incidence of maternal mortality & morbidity Legalizes abortion services Promotes access to safe abortion services to women Offers protection to medical practitioners who otherwise would be penalized under the Indian Penal Code (sections 315-316)

27. legal abortions Abortions are termed legal only when all the following conditions are met: – Termination done by a medical practitioner approved by the Act – Termination done at a place approved under the Act – Termination done for conditions and within the gestation prescribed by the Act – Other requirements of the rules & regulations are complied with

28. applications Continuation of pregnancy constitutes risk to the life or grave injury to the physical or mental health of woman Substantial risk of physical or mental abnormalities in the fetus as to render it seriously handicapped Pregnancy caused by rape (presumed grave injury to mental health) Contraceptive failure in married couple (presumed grave injury to mental health)

29. place of conducting abortion  A hospital established or maintained by Government or  A place approved for the purpose of this Act by a District-level Committee constituted by the government with the Chief Medical Health Officer as Chairperson

30. MTP act amendment 2002 Decentralizes site registration to a 3-5 member district level committee chaired by the CMO/DHO Approval of sites that can perform MTPs under the act can now be done at the district level Stricter penalties for MTPs being done in a unapproved site or by a persons not permitted by the act

31. medical abortions MTP using Mifepristrone (RU 486) & Misoprostol approved for up to 7 weeks termination Only a Registered Medical Practitioner (as defined by the MTP Act) can prescribe the drugs Has to follow MTP Act, Rules & Regulations Can prescribe in his/her clinic, provided he/she has access to an approved place Should display a certificate from owner of approved place agreeing to provide access

32. who can perform MTP A medical practitioner (RMP) – who has a recognized medical qualification as defined in clause (h) of section 2 of Indian Medical Council Act, 1956 – Whose name has been entered in a State Medical Register and – Who has such experience or training in Gynecology and Obstetrics as prescribed by Rules made under the Act

33. For termination up to 12 weeks: – A practitioner who has assisted a registered medical practitioner in performing 25 cases of MTP of which at least 5 were performed independently in a hospital established or maintained or a training institute approved for this purpose by the Government

34. For termination up to 20 weeks – A practitioner who holds a post-graduate degree or diploma in Obstetrics and Gynecology – A practitioner who has completed six months house job in Obstetrics and Gynecology – A practitioner who has at least one-year experience in practice of Obstetrics and Gynecology at a hospital which has all facilities – A practitioner registered in state medical register immediately before commencement of the Act, experience in practice of Obstetrics and Gynecology for a period not less than three years.

35. approval of place for sites upto 12 weeks for sites upto 20 weeks Gynecology examination/ labor table • sterilization equipment • Drugs & parental fluids • Back up facilities for treatment of shock • Facilities for transportation All requirements for up to 12 weeks + • Operation table and instruments for performing abdominal or gynecological surgery • Anesthetic equipment, resuscitation equipment and sterilization equipment • Drugs & parental fluids notified for emergency use, notified by Government of India from time to time

36. regulatory body: District Level Committee District level MTP Committee – Minimum of 3 & Maximum of 5 members including chairperson (CM H O) Composition of the committee: – One medical person (Gyne/Surgeon/Anestheist) – One member from local medical profession; NGO & Panchayati Raj Institution of the district. – At least one member shall be a woman. Tenure 2 calendar years – NGO members shall not have more than 2 terms

37. implications of amendment Simplifies registration of sites which can be done at district level now Providers can get their sites approved for providing abortions under the MTP Act for 1st trimester only or up to 20 weeks and thereby come under the protective cover of the MTP Act Offers potential to increase number of approved sites, which would enable women to access safe abortion services Effective implementation will help to bring all abortions within legal frame work

38. incentives for family planning

39. incentives for local sellers for temporary contraception The Social Marketing Organisations are given Deluxe Nirodh condom at Rs.2.00 per packet of 5 pieces and this is sold @ Rs.3/- per packet of 5 pieces to the consumer. One cycle of Oral Pills, which is required for one month, is given to the SMOs @ Re.1.60/- and it is sold to the consumer @ Rs.3/- per strip (cycle) under the brand name- “Mala–D”.

40. incentive for ensuring spacing at birth implemented in in 18 states including Empowered Action Group states like Bihar, UP etc, Gujarat, Haryana and north east states Rs. 500/- to ASHA for delaying first child birth by 2 years after marriage; Rs. 500/- to ASHA for ensuring spacing of 3 years after the birth of 1st child and Rs. 1000/- in case the couple opts for a permanent limiting method up to 2 children only

41. compensation schemes for permanent method - public facilities states type of operation acceptor ASHA/ health worker others total 11 High Focus States (UP, BH, MP, RJ, CG, JH, OD, UK, AS, HR, GJ) vasectomy 2000 300 400 2700 tubectomy 1400 200 400 2000 Other High Focus States (NE States, J&K, HP) vasectomy 1100 200 200 1500 tubectomy 600 150 250 1000 Non High Focus States vasectomy 1100 200 200 1500 tubectomy [BPL+SC/ST only] 600 150 250 1000 tubectomy [APL] 250 150 250 650

42. compensation scheme for permanent method - private facility states type of operation facility others/ Acceptor total 11 High Focus States (UP, BH, MP, RJ, CG, JH, OD, UK, AS, HR, GJ) vasectomy 2000 1000 3000 tubectomy 2000 1000 3000 Other High Focus States (NE States, J&K, HP) vasectomy 1300 200 1500 tubectomy 1350 150 1500 Non High Focus States vasectomy 1300 200 1500 tubectomy 1350 150 1500