Reproductive and child health programme phase I AND II

REPRODUCTIVE AND CHILD HEALTH PROGRAME PHASE I AND II

1. SEMINAR ON rch -I and rch -ii Presented by- Pinki barman

2. Introduction Reproductive and child health approach has been defined as "people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well being, and couples are able to have sexual relations, free of fear of pregnancy and of contracting disease" The RCH phase-I programme incorporated the components relating child survival and safe motherhood and included two additional components, one relating to sexually transmitted disease (STD) and other relating to reproductive tract infection (RTI)

3. Definition Reproductive health “State of complete physical, mental and social well being and not merely the absence of disease or infirmity in all matters relating to reproductive systems and its functions and process”. Reproductive Approach "People have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the outcome of pregnancies is successful in terms of maternal and infant survival and well being, and couples are able to have sexual relations, free of fear of pregnancy and of contracting disease"

4. Milestones of Reproductive and child health programme( RCH Programme) 1880-  Establishment of training of dais in Amritsar 1902- Passing of first Midwifery Act in London to promote safe delivery 1923- Establishment of first family planning clinic at Pune 1946- Bhore Committee recommendation comprehensive and integrated health care 1952- National family planning programme was launched 1956- MCH centres become the integral part of PHCs 1961- Department of family planning was created 1971- MTP act

5. 1977- Renaming of family planning to family welfare 1978- Expanded programme of immunization 1985- Universal immunization programme 1992- Child survival and safe motherhood programme 15 TH October 1997- RCH Phase- I 1 ST April 2005- RCH Phase-II 2013- Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+ A) Strategy.

6. COMPONENTS OF REPRODUCTIVE AND CHILD HEALTH

7. RCH Phase-I Reproductive and Child Health (RCH) programme is a comprehensive sector wide flagship programme, under the umbrella of the Government of India's ( GoI ) National Health Mission (NHM), to deliver the RCH targets for reduction of maternal and infant mortality and total fertility rates. On 15th October 1997, Department of Family Welfare initiated the RCH programme

8. Objectives of RCH Phase-I To improve the implementation and management of policy by using a participatory planning approach and strengthening institutions to maximum utilization of the project resources. To improve quality, coverage and effectiveness of existing Family Welfare services. To gradually expand the scope and coverage of the Family welfare services to eventually come to a defined package of essential RCH services. Progressively expand the scope and content of existing FW services to include more elements of a defined package of essentials. Give importance to disadvantaged areas of districts or cities by increasing the quality and infrastructure of Family Welfare Services.

9. Components of RCH Phase-I

10. RCH Phase-I Interventions:

11. RCH phase-I interventions at district level Child Survival interventions i.e. immunization, Vitamin A (to prevent blindness), oral rehydration therapy and prevention of deaths due to pneumonia. Safe Motherhood interventions e.g. antenatal check up, immunization for tetanus, safe delivery, anaemia control programme. Implementation of Target Free Approach. High quality training at all levels. IEC activities. Specially designed RCH package for urban slums and tribal areas. District sub-projects under Local Capacity Enhancement. RTI/STD Clinics at District Hospitals (where not available)

12. Facility for safe abortions at PHCS by providing equipment, contractual doctors etc. Enhanced community participation through Panchayats , Women's Groups and NGOs. Adolescent health and reproductive hygiene.

13. Interventions in selected States/Districts: Screening and treatment of RTI/STD at sub-divisional level. Emergency obstetric care at selected FRUS by providing drugs. Essential obstetric care by providing drugs Staff Nurse at PHCS. Additional ANM at sub-centres in the weak districts for ensuring MCH care. Improved delivery services and emergency care by providing equipment kits, IUD insertions and ANM kits at sub-centres. Facility of referral transport for pregnant women during emergency to the nearest referral centre through Panchayat in weak districts.

14. Empowered Action Group (EAG) Eight states- Rajasthan, Uttar Pradesh, Uttarkhand , Bihar, Jharkhand, Madhya Pradesh, Chattisgarh and Orissa  are called 'Empowered Action Group' (EAG). The reason is their development that determines the development of the nation. The rest of the states are called Non-EAG states.

15. District Surveys- The RCH programme conducts district based rapid household survey to assess the reproductive health status of women

16. RCH-PHASE II RCH-phase II began from 1st April, 2005, the focus of the programme is to reduce maternal and child morbidity and mortality with emphasis on rural health care

17. STRATEGIES

18. New initiatives

19. JANANI SURAKSHA YOJANA

20. salient features of Janani Suraksha Yojana It is a 100 per cent centrally sponsored scheme Under National Rural Health Mission, it integrates the benefit of cash assistance with institutional care during antenatal, delivery and immediate post-partum care. Category Rural Area Urban Area Mother’s package ASHA’s Package Total Rs Mother’s package ASHA’s Package Total Rs LPS 1400 600 2000 1000 400 1400 HPS 700 600 1300 600 400 1000

21. The eligibility of cash assistance is as follows In low performing states (LPS): All women, including those from SC and ST families, delivering in government health centres like sub-centre, primary health centre, community health centre, first referral unit, general wards of district and state hospitals or accredited private institutions. In high performing states (HPS): Below poverty line women, and the SC and ST pregnant women delivering in Govt. health centres or accredited private institutes.

22. The limitation of cash assistance for institutional delivery under jsy In low performing states: All births, delivered in health centre, government or accredited private health institutions will get the benefit. In high performing states the benefit is only up-to 2 live births.

23. Components asha packages under jsy Cash assistance for referral transport for pregnant women to go to the nearest health centre for delivery (should not be less than Rs. 250/-) Cash incentive: This should not be less than Rs. 200/- per delivery . ASHA should get her money after her post-natal visit to the beneficiary, and when the child has been immunized for BCG and Balance amount to be paid to ASHA in lieu of her services rendered by her. The payment should be made at the hospital/health institution itself.

24. Vandemataram scheme

25. Safe abortion services Facilities are provided under RCH Phase-II- Medical method of abortion Termination of early pregnancy with two drugs Mifepristone (RU 486) followed by Misoprostol . Manual Vacuum Aspiration (MVA)

26. Village Health and Nutrition Day- The VHND is to be organized once every month (preferably on Wednesdays , and for those villages that have been left out, on any other day of the same month) at the AWC in the village

27. Pregnancy tracking

28. JANANI-SHISHU SURAKSHA KARYAKRAM (JSSK)

29. PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN (PMSMA)

30. Objectives of PMSMA Ensure at least one antenatal checkup for all pregnant women in their second or third trimester by a physician/specialist Improve the quality of care during ante-natal visits. Identification and line-listing of high risk pregnancies based on obstetric/ medical history and existing clinical conditions. Appropriate birth planning and complication readiness for each pregnant woman especially those identified with any risk factor or comorbid condition. Special emphasis on early diagnosis, adequate and appropriate management of women with malnutrition. Special focus on adolescent and early pregnancies as these pregnancies need extra and specialized care

31. Key Features of PMSMA PMSMA is based on the premise Antenatal checkup services would be provided by OBGY specialists / Radiologist/physicians. A minimum package of antenatal care services (including investigations and drugs) would be provided to the beneficiaries on the 9th day of every month. Using the principles of a single window system. Special efforts would be made to reach out to women who have not registered for ANC. Pregnant women would be given Mother and Child Protection Cards and safe motherhood booklets.

32. Identification and follow up of high risk pregnancies- Green Sticker- for women with no risk factor detected. Red Sticker – for women with high risk pregnancy ‘ IPledgeFor9 ’ Achievers Awards

33. SUMAN ( Surakshit Matritva Aashwasan )

34. LAQSHYA PROGRAMME

35. ANAEMIA MUKT BHARAT PROGRAMME

36. INTENSIFIED YEAR-ROUND BEHAVIOUR CHANGE COMMUNICATION CAMPAIGN (SOLID BODY, SMART MIND) INCLUDING ENSURING DELAYED CORD CLAMPING IN NEWBORNS -Various activities prepared for behaviour change include sensitization meetings for the media, school teachers and administration, faith leaders, panchayat leaders, Village Health Sanitation and Nutrition Committee (VHSNC), etc. Year-round broadcast of messages for ‘Anemia Mukt Bharat’ should be carried out through mass media and social media ( Whatsapp and Twitter). -For community- and school-level communication, morning assemblies at schools will be utilized to discuss ‘nutrition and anemia’. Youth festivals organized at school platform will also be utilized to generate discussions and dialogue on anemia and nutrition. Monthly meeting of ASHA and mothers’ group will also be held at the existing platforms such as monthly Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) sites, monthly meetings as planned under Mother’s Absolute Affection (MAA) programme , weekly Self Help Groups (SHGs) meeting under the State Rural Livelihood Mission ( Maitri Baithaks ), etc. -Special press advertisements on occasions such as National Nutrition Week, National Deworming Day, Women’s Day, World’s Breastfeeding Week, and World Health Day including engagements with celebrities (local, national and international) will be used to amplify the communication strategy. -A comprehensive communication package for the strategy is available for use by the States which may be adapted as per requirement. These can be downloaded from the Anemia Mukt Bharat portal: www.anemiamuktbharat.info States can develop appropriate behaviour change communication plans through a range of communication channels such as using mass media through mobile phones, out-bound calls or text messages and interactive voice response system (IVRS), etc. as a need-based communication strategy. -Promotion and monitoring of delayed clamping of the umbilical cord for at least 3 minutes (or until cord pulsations cease) for newborns across all health facilities will be carried out for improving the infant’s iron reserves up to 6 months after birth. Simultaneously, all birth attendants should make an effort to ensure early initiation of breastfeeding within 1 hour of birth.

37. Testing and treatment of anemia with focus on pregnant women and school going adolescents Target group A Children 6–59 months Who will screen and place of screening ANM: VHND/sub-centre/session site RSBK team: AWC/school Medical Officer: health facility Periodicity • RBSK/ANM: as per scheduled microplan • MO: opportunistic If Haemoglobin is 7–10.9 g/dl (mild and moderate anemia) First level of treatment (at all levels of care) 3 mg of iron/kg/day for 2 months • For children 6–12 months (6–10.9 kg): 1 ml IFA syrup, once a day • For children 1–3 years (11–14.9 kg): 1.5 ml IFA syrup, once a day • For children 3–5 years (15–19.9 kg): 2 ml IFA syrup, once a day Line listing for all anemic children to be maintained by the ANM/ ASHA/ AWW Follow-up • Every month by ANM at VHND • Hb estimation after 2 months for completing 2 months of treatment to document Hb >= 11g/dl • Monitoring by ASHA for compliance of IFA syrup every 14 days for a period of 2 months If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose If no improvement after first level of treatment In case the child has not responded to the treatment of anemia with daily dose of iron for 2 months, refer the child to the FRU/DH medical offi cer / paediatrician /physician for further investigation

38. Target group B Children 5–9 years Who will screen and place of screening RSBK teams will screen in-school and out-of-school children for anemia. All children with clinical signs and symptoms of anemia will be referred to SC/PHC for Hb estimation and further management Periodicity • Once a year • Opportunistic screening, e.g., routine Hb assessment of sick children presented to health facility If Haemoglobin is 8–11.4 g/dl (mild and moderate anemia) First level of treatment (at all levels of care) 3 mg of iron/kg/day for 2 months Line listing of all anemic cases to be maintained in the school register for Iron Folic Acid supplementation and given to the ANM/LHV/Multiple Purpose Health Worker for designated area Follow-up • Class teacher/ Nodal teacher at school to orient parents during Parent Teacher Meeting (PTM) for compliance of treatment • Parents to ensure follow-up of child after 30 days and 60 days at nearest SC/health facility • Follow-up by ANM/LHV/MPW of designated area, as feasible. • Hb estimation after completing 2 months of treatment to document Hb >=11.5 g/dl • If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose If no improvement after first level of treatment In case the child has not responded to the treatment of anemia with daily dose of iron for 2 months, refer the child to the FRU/DH medical offi cer / paediatrician /physician for further investigation If Haemoglobin is <8 g/dl (severe anemia) Treatment • Refer urgently to District Hospital/First Referral Unit • Management of severe anemia in children of 5–9 years is to be done by the medical officer at the First Referral Unit/District Hospital based on investigation

39. Target group All school-going adolescents 10–19 years in government/government-aided schools Who will screen and place of screening In school premises by RSBK team Periodicity Annually Mild and Moderate Anemia ( Hb cut-off as per Table 1) First level of treatment (at all levels of care) Two IFA tablets (each with 60 mg elemental iron and 500 mcg folic acid), once daily, for 3 months, orally after meals. Follow-up • Line listing of all anemic cases to be maintained in the school register for Iron Folic Acid supplementation and given to the ANM/LHV/MPHW of designated area • Follow-up by ANM/LHV/MPHW of designated area, as feasible for the state • Parents to ensure follow-up of adolescent after 45 days to 90 days at the nearest sub-centre/ health facility • If haemoglobin levels have improved to normal level, discontinue the treatment, but continue with the prophylactic IFA dose If no improvement after first level of treatment If no improvement after three months of treatment (i.e., still in mild/moderate category), ANM/MO of nearest facility to refer adolescent to First Referral Unit (FRU)/District Hospital (DH) If Haemoglobin is <8 g/dl (severe anemia) First dose of treatment Management of severe anemia in adolescents 10–19 years is to be done by the medical offi cer at FRU/DH based on investigation and subsequent diagnosis

40. Target group Pregnant women registered for antenatal care Who will screen and place of screening Health service provider at any ANC contact, including Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) Periodicity At every ANC contact If Haemoglobin is 10–10.9 g/dl (mild anemia) First level of treatment (at all levels of care) • Two tablets of Iron and Folic Acid tablet (60 mg elemental Iron and 500 mcg Folic Acid) daily, orally given by the health provider during the ANC contact • Parental iron (IV Iron Sucrose or Ferric Carboxy Maltose (FCM) may be considered as the fi rst line of management in pregnant women who are detected to be anemic late in pregnancy or in whom compliance is likely to be low (high chance of lost to follow-up) Follow-up • Every 2 months for compliance of treatment by health provider during the contact • If haemoglobin levels have come up to normal level, discontinue the treatment and continue with the prophylactic IFA dose If no improvement after first level of treatment If no improvement in haemoglobin (<1 g/dl increase) after one month of treatment, refer to First Referral Unit (FRU)/District Hospital (DH) by health provider The case to be referred to FRU/DH for further investigations for cause of anemia and may be managed with IV Iron Sucrose/FCM If Haemoglobin is 7–9.9 g/dl (moderate anemia) First level of treatment (at all levels of care) Two tablets of Iron and Folic Acid tablet (60 mg elemental Iron and 500 mcg Folic Acid) daily, orally given by the health provider during the ANC contact • Parental iron (IV Iron Sucrose or FCM) may be considered as the fi rst line of management in pregnant women who are detected to be anemic late in pregnancy or in whom compliance is likely to be low (high chance of lost to follow-up)

41. Follow-up • Every 2 months for compliance of treatment by health provider at regular ANC clinics/PMSMA/VHND platform. • The contact is to be utilized by the health provider to also conduct haemoglobin estimation of the anemic cases every month. If haemoglobin levels have come up to normal level, discontinue the treatment and continue with the prophylactic IFA dose. If no improvement after first level of treatment If no improvement in haemoglobin (<1 g/dl increase) after two month of treatment, refer to First Referral Unit (FRU)/District Hospital (DH) by health provider The case to be referred to FRU/DH for further investigations for cause of anemia and may be managed with IV Iron Sucrose/FCM If Haemoglobin is 5.0–6.9 g/dl (severe anemia) First level of treatment Management of severe anemia in pregnant women will be done by the medical offi cer at PHC/CHC/FRU/DH The treatment will be done using IV Iron Sucrose/Ferric Carboxy Maltose (FCM) by the medical officer *Immediate hospitalization recommended in the third trimester of pregnancy at a health facility where round-the-clock specialist care is available Follow-up after first level of treatment After the fi rst level of treatment, monthly or as prescribed by the medical officer Treatment protocol if no improvement As prescribed by the medical officer Note For severely anemic pregnant women with haemoglobin less than 5 g/dl, immediate hospitalization irrespective of period of gestation where round-the-clock specialist care is available. This is to be done till normal level of haemoglobin is achieved.

42. MANDATORY PROVISION OF IRON AND FOLIC ACID FORTIFIED FOODS IN GOVERNMENT-FUNDED HEALTH PROGRAMMES The Government of India has mandated the use of fortified salt, wheat flour and oil in foods served under Integrated Child Development Services (ICDS) and Mid-day Meal (MDM) schemes to address micronutrient deficiencies. In addition, all health facility-based programmes where food is being provided are mandated to provide fortified wheat, rice (with iron, folic acid and vitamin B12), and double fortified salt (with iodine and iron), and oil (with vitamin A and D) as per standards for fortification of staple foods (salt, wheat, rice, milk and oil) prescribed and notified by the Food Safety and Standard Authority of India (FSSAI, 2016)

43. NTENSIFYING AWARENESS, SCREENING AND TREATMENT OF NON-NUTRITIONAL CAUSES OF ANEMIA IN ENDEMIC POCKETS, WITH SPECIAL FOCUS ON MALARIA, HAEMOGLOBINOPATHIES AND FLUOROSIS MALARIA: As the country is committed towards malaria elimination by 2030, States have identified high malaria-endemic districts/ blocks/sub- centres and villages for intensification of malaria prevention and control activities. The prevention and control strategy for nutritional anemia is to be integrated with active and passive case detection and management protocols as per the guidelines of National Vector Borne Disease Control Program (NVBDCP), MoHFW , GoI . The testing of malaria and anemia will be integrated in the identified malaria endemic regions. Fixed days for screening of anemia at Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) sites and annually by Rashtriya Bal Swasthya Karyakram teams in schools will be utilized to provide screening for malaria as per NVBDCP, MoHFW guidelines. Indoor Residual Spray (IRS) before and after the monsoon season will be carried out with the appropriate insecticides in school premises and residential areas as per the malaria burden as decided by NVBDCP. To prevent malaria, NVBDCP has provided Long Lasting Insecticide Nets (LLINs) in all high endemic areas. Anaemia Mukt Bharat will play a key role for utilization of these LLINs by all target groups especially pregnant mothers and under-five children by promoting IEC/BCC.

44. HAEMOGLOBINOPATHIES: An integrated strategy for comprehensive prevention, screening and management of haemoglobinopathies should be provided at the existing service delivery platforms. Pre-marital and pre-conception screening and counselling services for informing the community about appropriate preventive options will be provided in the endemic districts of the country. Existing platforms such as AWCs, SCs and Health and Wellness Centres and events such as VHNDs, Nutrition week, Breastfeeding week, Women’s Day, World Thalassemia Day, etc. will be utilized to generate discussions and dialogue on nonnutritional causes of anemia in the endemic districts. Activities such as quizzes and assisted educative talks (with distribution of informative booklets) can be done during Adolescent Health Days to engage adolescents. Screening for haemoglobinopathies should be integrated with ANC services during the first trimester of pregnancy in the endemic districts. Women identified with severe anemia should be referred to higher centres for further investigations and if found positive, the husband is to be screened for carrier status. If the couple is found positive, they are to be referred to a higher centre for prenatal diagnosis before twenty weeks of pregnancy. Appropriate treatment should be provided as per the National Guidelines on Prevention and Control of Haemoglobinopathies (2016).The treatment of anemia using parental iron administration is contraindicated in sickle cell disease patients.

45. FLUOROSIS Identification of fluoride-affected habitations Activities for anemia control due to fluorosis : Capacity building

46. CHILD HEALTH COMPONENTS Nutritional rehabilitation centres (NRCS) Severe acute malnutrition is an important contributing factor for most deaths among children suffering from common childhood illness such as diarrhoea and pneumonia. Deaths among these malnourished children are preventable, provided timely and appropriate actions are taken. NRCs are facility based units providing medical and nutritional care to Severe Acute Malnutrition (SAM) children under 5 years of age who have medical complications

47. The services provided at the NRCs include- 24 hours care and monitoring of the child; Treatment of medical complication; Therapeutic feeding Sensory stimulation and emotional care; Counselling on appropriate feed, care and hygiene; Demonstration and practice-by-doing on the preparation of energy dense food using locally available, culturally acceptable and affordable food items; Social assessment of the family to identify and address contributory factors and Follow up of the children discharged

48. Management of medical complications in a child with SAM of health facility Triage Assessment at admission Principles of hospital-based management Stabilization Phase Transition Phase Micronutrient supplementation Follow up of children discharged from NRC Age Vitamin A dose <6 month 50,000 IU 6-12 month or if weight s <8 kg 100,000 IU >12 months 200,000 IU

49. Navjat Shishu Suraksha Karyakram (NSSK) NSSK is a programme aimed to train health personnel in basic newborn care and resuscitation, has been launched to address care at birth issues i.e. Prevention of Hypothermia, Prevention of Infection, Early initiation of Breast feeding and Basic Newborn Resuscitation .

50. Integrated management of neonatal and childhood illness (IMNCI) The Indian version of IMCI has been renamed as Integrated Management of Neonatal and Childhood Illness (IMNCI). It is the central pillar of child health interventions under the RCH Il strategy. IMNCI strategy is one of the main interventions under RCH-II/NRHM. It focuses on preventive, promotive and curative aspects of the programme.

51. Pre-service IMNCI Facility based IMNCI (F-JMNCI) Facility based newborn care Newborn Care Corner (NBCC) Newborn Stabilization Unit (NBSU) Special Newborn Care Unit (SNCU) Health facility All newborns at birth Sick newborns Primary health centre /PHC/SC referred as MCH level I Newborn care corner Prompt referral Community health centre (CHC)/First referral (FRU) identified as MCH Level (NBSU). Newborn care corner unit in labor rooms and in II operation theatre. Newborn stabilization unit District hospital identified as MCH Level Ill. Newborn care corner in labor room and in operation theatre Special newborn care unit (SNCU). Health facility All newborns at birth Sick newborns

52. CRITERIA FOR ADMISSION TO NBSU Newborn presenting with any of the following signs to a facility with neonatal stabilization unit requires admission for initial stabilization and transfer to SNCU- Apnea or gasping. Respiratory distress (Rate>70/min with severe retractions/grunt) Hypothermia <35.4°C Central cyanosis Shock (cold periphery with capillary filling time (CFT) more than 3 seconds and weak and fast pulse) Hyperthermia (>37.5°C) Significant bleeding that requires blood or component transfusion.

53. CRITERIA FOR ADMISSION TO SNCU Birth weight <1800 g or gestation <34 weeks. Large baby (>4.0 kg). Perinatal asphyxia. Apnea or gasping. Refusal to feed. Respiratory distress (rate>60/min or grunt/retractions). Severe jaundice (appears <24 hrs/stains palms and soles/lasts>2 weeks). Hypothermia <35.4°C, or hyperthermia (>37.5°C). Coma, convulsions or encephalopathy. Abdominal distension. Diarrhoea/dysentery. Bleeding. Major malformations.

54. Criteria for discharge from SNCU: Newborn is able to maintain temperature without radiant warmer. Newborn is haemodynamically stable (normal CFT, strong peripheral pulse). Newborn accepting breast-feeds well. Newborn has documented weight gain for 3 consecutive days; and the weight is more than 1.5 kg. Primary illness has resolved.

55. HOME BASED NEWBORN CARE (HBNC) Home based newborn care is aimed at improving newborn survival. The strategy of universal access to home based newborn care must complement the strategy of institutional delivery to achieve significant reduction in postpartum and neonatal mortality and morbidity.

56. objectives The provision of essential newborn care to all newborns and the prevention of complications. Early detection and special care of preterm and low birth weight newborns. Early identification of illness in the newborn and provision of appropriate care and referral. Support the family for adoption of healthy practices and build confidence and skills of the mother to safeguard her health and that of the newborn.

57. Responsibilities of asha Mobilize all pregnant mothers and ensure that they receive the full package of antenatal care. Undertake birth planning and birth preparedness with the mother and family to ensure access to safe delivery. Provide newborn care through a series of home which include the skills for: Weighing the newborn Measuring newborn temperature Ensuring warmth Supporting exclusive breast-feeding by teaching the mother proper positioning and attachment for initiating and maintaining breast-feeding Diagnosing and counselling in case of problems with breast-feeding Promoting hand-washing Providing skin, cord and eye care Health promotion and counselling mothers and families on key messages on newborn care which includes discouraging unhealthy practices such as early bathing, and bottle feeding

58. Ensuring prompt identification of sepsis or other illnesses. Provide immediate newborn care, in case of those deliveries that do not occur in institutions. ASHA will make visits to all newborns according to specified schedule upto 42 days of life. The schedule of visit is as follows: Six visits in the case of institutional delivery - Day 3, 7, 14, 21, 28, and 42. Seven visits in the case of home delivery (Day 1, 3, 7, 14, 21, 28 and 42). In cases of Caesarean section delivery, where the mother returns home after 5-6 days, ASHAS are entitled to full incentive of Rs. 250 if she completes all five visit starting from Day 7 to Day 42. In cases when a newborn is discharged from SNCU, ASHA are eligible to full incentive amount of Rs. 250 for completing the remaining visits

59. In cases where the woman delivers at her maternal house and returns to her husband's house, two ASHAS undertake the HBNC visits, i.e., one at maternal house immediately after delivery, and another one at husband's house when the new-born returns home or vice versa. In such cases the HBNC incentive of Rs. 250 can be divided into two parts in a way that each ASHA who completes 3 visits or more is entitled to Rs. 125. In these instances, if an ASHA undertakes less than 3 visits, she would not be to HBNC incentive. In cases of twin or triples the incentive amount for ASHA would be two time of the regular HBNC incentive of Rs. 250/- (i.e., Rs. 500/-) or three times of Rs. 250/ (i.e., Rs. 750/-) respectively. The incentive money is paid to ASHA on 45th day subject to the following: Record of birth weight in the mother and child protection Immunization of newborn with BCG, first dose of OPV. hep B and DPT/ pentavalent vaccine and entry into the mother and child protection card Registration of birth Both mother and newborn are safe until 42nd day of delivery.

60. Rashtriya Bal SwasthyaKaryakram (RBSK) RBSK is a new initiative launched in February 2013. It includes provision for Child Health Screening and Early Intervention Services through early detection and management of 4 Ds, prevalent in children. These are defects at birth, diseases in children, deficiency conditions and development delays including disabilities.

61. Defects on birth- Neural tube defects Down’s syndrome Cleft lip and palate Talippes Development dysphasia of hips. Congenital cataract Congenital deafness Congenital heart disease Retinopathy of prematurity 2. Deficiencies- Anaemia especially severe anaemia Vitamin A deficiency Vitamin D deficiency Severe malnutrition Goiture

62. Programme Implementation For newborn: Facility based newborn screening at public health facilities, by existing health manpower. Community based newborn screening at home through ASHAs for newborn till 6 weeks of age during home visits. For children 6 weeks to 6 years: Anganwadi centre based screening by dedicated Mobile Health Teams, For children 6 years to 18 years: Government and Government aided school based screening by dedicated Mobile Health Teams.

63. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH (RMNCH+A) STRATEGY, 2013 The RMNCH+A strategy is based on provision of comprehensive care through the five pillars, or thematic areas of reproductive, maternal, neonatal, child, and adolescent health, and is guided by central tenets of equity, universal care, entitlement, and accountability. In June 2012, the Government of India, Ethiopia, USA and the UNICEF convened the "Global Child Survival Call to Action: A Promise to Keep" summit in Washington, DC to energize the global fight to end preventable child deaths through targeted interventions in effective, life-saving interventions for children.

64. Goals and targets Reduction of Infant Mortality Rate (IMR) to 25 per 1,000 live births by 2017 Reduction in Maternal Mortality Ratio (MMR) to 100 per 100,000 live births by 2017. Reduction in Total Fertility Rate (TFR) to 2.1 by 2017.

65. key features of RMNCH+A Strategy Health systems strengthening (HSS) focusing on infrastructure, human resources, supply chain management, and referral transport measures. Prioritization of high-impact interventions for various lifecycle stages. Increasing effectiveness of investments by prioritizing geographical areas based on evidence. Integrated monitoring and accountability through good governance, use of available data sets, community involvement, and steps to address grievance. Broad-based collaboration and partnerships with ministries, departments, development partners, civil society, and other stakeholders.

66. Continuum of care across life cycle and different levels of health system

67. intervention Adolescent Health Programme Adolescent Reproductive and Sexual Health programme (ARSH) Facility based health services-Adolescent Friendly, Health Clinics; Counselling-Dedicated ARSH and ICTC counselling Community based interventions-Outreach activities; and Capacity building for service providers.

68. Weekly Iron and Folic Acid Supplementation (WIFS) Ministry of Health and Family Welfare has launched the Weekly Iron and Folic Acid Supplementation (WIFS) Programme to meet the challenge of high prevalence and incidence of anaemia amongst adolescent girls and boys. The long term goal is to break the intergenerational cycle of anaemia, the short term benefit is of a nutritionally improved human capital. The programme, implemented across the country, both in rural and urban areas, will cover 10.25 crore adolescents.

69. Menstrual Hygiene Scheme Community based health education and outreach in the target population to promote menstrual health Ensuring regular availability of sanitary napkins to the adolescents; Sourcing and procurement of sanitary napkins Storage and of sanitary napkins to the adolescent girls; Training of ASHA and nodal teachers in menstrual health; and Safe disposal of sanitary napkins.

70. Rashtriya Kishor Swasthya Karyakram he Ministry of Health & Family Welfare  has launched a health programme for adolescents, in the age group of 10-19 years, which would target their nutrition, reproductive health and substance abuse, among other issues. The Rashtriya Kishor Swasthya Karyakram was launched on 7th January, 2014.  The key principles of this programme is adolescent participation and leadership, Equity and inclusion, Gender Equity and strategic partnerships with other sectors and stakeholders. The programme envisions enabling all adolescents in India to realize their full potential by making informed and responsible decisions related to their health and well being and by accessing the services and support they need to do so.

71. objectives Improve Nutrition Reduce the prevalence of malnutrition among adolescent girls and boys (including overweight/obesity) Reduce the prevalence of iron-deficiency anaemia (IDA) among adolescent girls and boys Improve Sexual and Reproductive Health Improve knowledge, attitudes and behaviour , in relation to SRH Reduce teenage pregnancies Improve birth preparedness, complication readiness and provide early parenting support for adolescent parents

72. Enhance Mental Health Address mental health concerns of adolescents Prevent injuries and violence Promote favourable attitudes for preventing injuries and violence (including GBV) among adolescents Prevent substance misuse Increase adolescents' awareness of the adverse effects and consequences of substance misuse Address conditions for NCDs Promote behaviour change in adolescents to prevent NCDs such as cancer, diabetes, cardio-vascular diseases and strokes

73. strategies a. Community based interventions Peer Education (PE) Quarterly Adolescent Health Day (AHD) Weekly Iron and Folic Acid Supplementation Programme (WIFS) Menstrual Hygiene Scheme (MHS)   b. Facility based interventions Strengthening of Adolescent Friendly Health Clinics (AFHC) within Health & Family Welfare - FP, MH ( incl VHND), RBSK, National Tobacco Control Programme,National Mental Health Programme , NCDs and IEC with other departments/schemes – Social Welfare (ICDS,SABLA), Youth Affairs and Sports etc.(Adolescent Empowerment Scheme, National Service Scheme, NYKS, etc) c. Social and Behaviour Change Communication with focus on Inter Personal Communication

74. Maternal health Janani Suraksha yojona Janani shishu suraksha karyakram Pradhan mantri surakshit matriva abhiyan Comprehensive abortion care Skilled birth attendence Mother and child health wings Delivery points Monthly village health and nutrition days Mother and child protection card Dakshata

75. Comprehensive abortion care The comprehensive abortion care aim to improve abortion care services under NRHM. CAC under RMNCH+A Establishment of maternal and child health wings. Strengthening delivery points on priority for the provision of services. Conducting maternal death review to improve the quality of obstetric care.

76. WOMEN CENTERED APPROACH

77. Maternal and Child Health (MCH) Wing Most health facilities, especially those at secondary and tertiary level are having high case load of pregnant women and newborn due to increase in institutional deliveries following launch of JSY and JSSK. Therefore, it has been decided that dedicated Maternal and Child Health Wings will be established in high case load facilities with adequate provision of beds. The new MCH wings will be comprehensive units (30/50/100 bedded) with antenatal waiting rooms, labour wing, essential newborn care room, SNCU, operation theatre, blood storage units and a postnatal ward and an academic wing. This will ensure provision of emergency maternal and newborn care services as well as 48 hours stay, i.e., quality postnatal care to mothers and newborns

78. DELIVERY POINT The provision of services for delivery care in a health facility generally serves as an important indicator to assess whether the facility is optimally functional or not. the health facilities designated as L1, L2 and L3, there are some facilities which are conducting deliveries above a minimum bench mark (minimum 3 normal deliveries per month at L1; minimum 10 deliveries per month, including management of complications, at L2; and minimum 20-50 deliveries per month including C-section at L3). These are designated as delivery points

79. Dakshata In consonance with Government of India’s commitment to reduce maternal and newborn mortality in the country, Dakshata program has been launched to enable the service providers in providing high quality services during childbirth in institutions. Objective 1: To strengthen the competency of the providers of the labour room, including medical officers, staff nurses, and ANMs to perform evidence-based practices as per the established labour room protocols and standards. Objective 2: To implement enabling strategies to ensure transfer of learning towards improved adherence to evidence based clinical practices Objective 3: To improve the availability of essential supplies and commodities in the labour room and the postpartum wards. Objective 4: To improve accountability of service providers through improved recording, reporting and utilization of data Objective 5 (intermediate term objective): Implementation of the MNH Tool kit at the delivery points, in a phased manner

80. CHILD HEALTH Home based newborn care and prompt referral. Facility based care of the sick newborns. Child nutrition and essential micronutrients supplementation. IMNCI “MAA”( mother absolute affection) program I ntensified Diarrhoea Control Fortnight (IDCF) National iron plus initiative( NIPI) India newborn action plan

81. “MAA”( mother absolute affection) program An intensified programme with an attempt to bring undiluted focus on promotion of breastfeeding, in addition to ongoing efforts through the health systems. The Programme would be launched at the national level on 5th August 2016. Main goal is to revitalize efforts towards promotion, protection and support of breastfeeding practices through health systems to achieve higher breastfeeding rates

82. Intensified Diarrhoea Control Fortnight (IDCF) a set of activities to be implemented in an intensified manner for prevention and control of deaths due to dehydration from diarrhoea across all States and Uts . Strategies- Improved availability and use of ORS and Zinc at the community Facility level strengthening to manage cases of dehydration Enhanced advocacy and communication on prevention and control of diarrhoea through IEC campaign.

83. National Iron Plus Initiative (NIPI) National Iron Plus Initiative (6 – 59 Months) This programme is for infants & preschool children (6- 59 months) in urban and rural areas. The programme implemented through the platform of AWCs. Bi weekly IFA syrup supplementation is done in AWCs. National Iron Plus Initiative (5 – 10 Years) This programme is for school going boys and girls (5-10 years) and out of school girls (5-10 years) in urban and rural areas. The programme implemented through the platform of Government/Government aided/ municipal schools and AWCs. The strategy involves a “fixed day – Monday’’ approach for IFA distribution. Teachers and AWWs will supervise the ingestion of the IFA tablet by the beneficiaries

84. INDIA NEWBORN ACTION PLAN (INAP) In India, Newborn Action Plan (INAP) developed in response to the global Every Newborn Action Plan (ENAP), was launched in June 2014. INAP defines the latest evidence on effective interventions which will not only help in reducing the burden of stillbirths and neonatal mortality, but also maternal deaths. The goal is to attain "Single Digit Neonatal Mortality Rate by 2030" and "Single Digit Stillbirth Rate by 2030".

85. Six pillar of intervention under inap

86. New initiative in assam Adarani Dropback Service under JSSK Scheme Boat Clinic Sanjeevani - Village Health Outreach Programme Assam Arogya Nidhi

87. Summary and conclusion