Rmnch +a 2019

It is one of the flagship programme.

1. Dr Mohan Lal Professor Department of Community Medicine, Govt. Medical College, Amritsar

2. Outline of Presentation Reproductive , Maternal , New born , child Plus Adolescent (RMNCH+A) Pregnancy and Child Birth Newborn & Child Health Adolescents Reproductive health & Family planning Monitoring

3. RCH to RMNCH+A?? Launched in February,2013 Continuum of care: Gives integrated packages of services for different stages of life. 5 impact indicators under 5 pillars to be implemented together, at same time, with high quality and coverage 3

4. 12 th plan MCH Goals Reduction in MMR to 100 per 100,000 live births Reduction in IMR to 25 per 1000 live births Reduction in TFR to 2.1 Reduce by half under nutrition in children under 3 years(46% to 23%) Reduce by half anemia among reproductive aged women (56% to 28%) Improve child Sex ratio (914 to 950)

5. Appropriately directs the states to focus their efforts on the most vulnerable population & disadvantaged groups in the country. Adolescent mothers: High risk pregnancy & chances of dying are twice than in women over age 20 Prevalence of Neonatal mortality (54.2/ 1000 LB) is higher among adolescent mothers (NFHS III, 2005-06 ) Anaemia is a major contributory factor in maternal deaths due to haemorrhage Why RMNCH+A approach?

6. New initiatives like the use of Score Card to track the performance

7. 5x5 matrix for high impact RMNCH+A interventions Reproductive Health Focus on spacing methods, particularly PPIUCD at high case load facilities Focus on interval IUCD at all facilities including subcentres on fixed days Home delivery of contraceptives(HDC) and Ensuring Spacing at Birth(ESB) through ASHA’s Ensuring access to Pregnancy Testing Kits Maintaining quality sterilization services Maternal Health Use MCTS to ensure early registration of pregnancy and full ANC Detect high risk pregnancies Equip delivery points with highly trained human resource and ensure equitable access to EmOC services through first referral units Review maternal, infant and child deaths for corrective actions V. Identify villages with high numbers of home deliveries 9

8. Newborn Health Early initiation and exclusive breastfeeding Home based newborn care through ASHA Essential new born care Special new born care units Community level use of gentamycin by ANM Child Health Complementary feeding, IFA supplementation and focus on nutrition Diarrhoea management at community level Management of pneumonia Full immunization coverage Rashtriya Bal Swasthya Karyakram 10

9. Janani Shishu Suraksha Karyakram (JSSK) To reduce out-of-pocket expenses related to maternal and newborn care. The scheme implemented across the country entitles all pregnant women delivering in public health institutions to absolutely free and no expense normal delivery (3 days), including caesarean section (7 days). Similar entitlements are in place for all sick newborn (first 30 days of life) accessing public health institutions for treatment. Free assured transport (ambulance service) from home to health facility, inter-facility transfer in case of referral and drop back is an entitlement

10. Post Natal care Postpartum care for mother & baby To ensure postpartum care for mothers & newborns, 48 hours of stay at the health facility is mandated in case of institutional delivery. Postnatal home visits are made by frontline workers(ASHA, ANM) irrespective of the place of delivery for 6 weeks.

11. Contd. Misoprostol for prevention of PPH:- In places with home deliveries >80 %, 3 tablets of Misoprostol ( 200mcg.) are given to pregnant women at 8 months of gestation . Taken immediately after delivery . Comprehensive safe MTP:- MVA facilities to be available at all CHCs and 50 % PHCs. Private & NGOs sector encouraged & frontline workers trained to provide confidential counseling & promote post abortion adoption of contraception.

12. Intensified Newborn Action Plan Recently launched with goal to achieve single digit Neonatal Mortality Rate & Still Birth Rate by 2030. • Six pillars of interventions include- 1. Preconception and antenatal care 2. Care during labor and child birth 3. Immediate newborn care 4. Care of healthy newborn 5. Care of small & sick newborn 6. Care beyond newborn survival

13. Navjaat Shishu Suraksha Karyakram (NSSK) Launched to address issues of care at birth. Doctors, ANM and Nurses posted at delivery points are trained in basic newborn care & resuscitation for 2 days. The saturation of all delivery points with Skilled Birth Attendance & NSSK trained personnel & functional Newborn Care Corners are the topmost priorities.

14. Facility-based care of the sick newborns: Special Newborn Care Units (SNCU) have been established at District Hospitals and tertiary care hospitals The goal is to have one SNCU in each district of the country and in health facilities with more than 3,000 deliveries per year Newborn Stabilization Unit ( NBSU), which is a four-bedded unit providing basic level of sick newborn care, is being established at Community Health Centers / First Referral Units

15. Follow up Services Follow up of the sick newborn after discharge Sick newborns discharged from health facilities should be followed up for Developmental Screening & Early Intervention & also provided special care or treatment required. During these follow ups, counseling on exclusive breastfeeding, complementary feeding, growth monitoring, and screening for neuro- developmental disorders (such as visual, hearing) done.

16. HOME-BASED NEWBORN CARE SCHEME Launched in 2011 to ensure Immediate postnatal care (especially in the cases of home delivery) & essential newborn care to all newborns up to the age of 42 days. Frontline workers (ASHAs) are trained and incentivized to provide special care to preterm and newborns discharged from Special Newborn Care Units (SNCUs). ASHA records weight in MCP card, ensures BCG-OPV-DPT vaccination, birth registration and maternal & child health.

17. Immunisation Goal of universal immunization. Pentavalent vaccine A combination vaccine(DPT + Hep -B + Hib ). New Vaccines • Rotavirus, rubella and inactivated poliovirus vaccine (IPV) will be made available to all children through India’s Universal Immunization Measles 2nd dose JE vaccine is now being provided in two dosages in some endemic districts across nine states. Mission Indradhanush • Launched on December 25, 2014.

18. Integrated management of common childhood illnesses Availability of ORS and Zinc should be ensured at all sub- centers & with all frontline workers Timely and prompt referral of children with fast breathing and/or lower chest in-drawing should be made to higher level of facilities . Training of health service providers (doctors and nurses), especially those at FRUs and District Hospitals in F-IMNCI

19. Rashtriya Bal Swasthya Karyakram This initiative aims to reach children annually in the age group 0-18 years Child health screening and early interventions services by mobile health teams at block level These teams will include - at least 2 doctors (MBBS /AYUSH qualified) – 2 paramedics The health screening to detect 4Ds: defects, deficiencies, diseases, development delays including disabilities

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21. Information & counseling on health issues: Platform to educate & counsel adolescents on behavior risk modification Screening for diabetes & other non-communicable diseases is proposed Service providers (teachers, AWW ANMs ) will be trained to screen for anxiety, stress, depression, suicidal tendencies and refer them to appropriate facility management of mental health disorders

22. Rashtriya Kishor Swasthya Karyakram (RKSK) launched on January 7, 2014.   C omprehensively address the health needs of adolescents A ccount for over 21% of the country’s population. RKSK will include a sharp focus on adolescents’ sexual health.

23. Adolescent The RKSK programme defines an adolescent as a person within 10-19 years of age, in urban and rural areas, includes both girls and boys, married and unmarried, poor and affluent, whether they are in school or out of school. The Rashtriya Kishor Swasthya Karyakram (RKSK) will bring in several new dimensions, such as – mental health, nutrition, substance misuse, gender based violence and non-communicable diseases. The programme introduces community based interventions through peer educators,

24. Intervention Packages Across Lifestyles National Iron + Initiative, including Weekly Iron & Folic Acid Supplementation on (WIFS) Program 2.Adolescent friendly health services 3.Promotion of menstrual hygiene practices among adolescent girls (10-19 years) in rural India

25. Promotion of Menstrual hygiene Scheme for promotion of menstrual hygiene among adolescent girls in rural India: This scheme promotes better health and hygiene among adolescent girls Sanitary napkins are provided under NRHM’s brand ‘Free days’ . These napkins are being sold to adolescent girls by ASHAs.

26. CARE THROUGH REPRODUCTIVE YEARS PRIORITY INTERVENTIONS Community based promotion and delivery of contraceptives Promotion of spacing methods Sterilization services Comprehensive abortion care Prevention and management of sexually transmitted infections 28

27. Postpartum I U C D insertion & sterilization: Postpartum IUCD insertion and sterilization Placement of trained providers for post-partum IUCD (PPIUCD) insertion at district and sub-district hospital level Training of Medical Officers in ‘ Minilap ’ for provision of Post-Partum Sterilization in high case load facilities Counselor ensure healthy timing and spacing between pregnancies

28. Implementation of (PC&PNDT) Act: The mission is to improve sex ratio at birth by regulating pre-conception & pre-natal diagnostic techniques misused for sex selection Key action: - Formation of PC&PNDT cells at state/district level, Strengthening of human resources as well as trainings & establishing appropriate infrastructure at all levels Building community opinion against sex selective abortion and feticide by sensitizing and mobilizing self-help groups and empowering women

29. Management of RTI and STI To be provided at all CHCs and FRUs and at 24 X 7 PHCs . For Syndromic management availability of color -coded kits, RPR testing kits for syphilis and HIV test should be ensured first at delivery points Service providers should be trained in Syndromic management of STI and RTI. Importantly services should be made available across entire reproductive age group including adolescents, youth & adults.

30. 32 Reproductive health Maternal health Newborn Family planning commodities: Tubal rings, IUCD 380A, IUCD 375 Injection Oxytocin Injection Vitamin K OCP’s, Condoms Tablet Misoprostol Mucous Extractor Emergency contraceptive pills (Levonorgestrel 1.5 mg) Injection Magnesium Sulphate Vaccines-BCG, Oral Polio vaccine, Hepatitis B Pregnancy testing kits (Nischay) Tablet Mifepristone List of Minimum Essential Commodities

31. 33 Child health Adolescent health ORS Tablet albendazole Zinc Sulphate Dispersable tablets Tablet dicyclomine Syrup Salbutamol and salbutamol nebulising solution Vaccines-DPT, Measles, OPV, HepB JE(19 States), Pentavalent vaccine Syrup Vitamin A

32. Health Systems Strengthening Case load based deployment of human resource at all levels Ambulance, drugs, diagnostics, reproductive health commodities Health education, demand promotion and behaviour change communication Supporting supervision and monitoring Public grievances redressal mechanism,client satisfaction and patient safety 34

33. Score Card is a simple management tool for converting available HMIS information into actionable points and assists in comparative assessment of District and Block performance 16 indicators selected based on life cycle approach ( RMNCH+A) representing various phases Overall composite index to measure performance of the districts Monitoring progress on RMNCH+A using Score Card

34. Pregnancy care Child birth Postnatal care, newborn & child health Reproductive age group 1st Trimester registration 4 ANC check-ups 100 IFA intake Obstetric complications attended TT2 injections SBA attending home deliveries Institutional deliveries C-Sectio n Newborns breastfed within 1 hour Women discharged in < 48 hours Newborns weighing less than 2.5 kg Newborns visited within 24hrs of home delivery 0 - 11 months old receiving Measles vaccine Post-partum sterilization to total female sterilization Male sterilization to total sterilization IUD insertions in public + private accredited institution Score Card: HMIS Indicators across the life cycle Score card : HMIS indicators across life cycle

35. Survey Based score card Indicators : 37 Mortality 1.Under5 mortality rate 2.Infant mortality rate 3.Neonatal mortality rate 4.Maternal mortality ratio Fertility 5.Total fertility rate 6.Births to women during age 15-19 out of total births

36. 38 Nutrition 7.Children with birth weight less than 2.5kg 8.Children under 3yrs who are underweight Gender 9.Child sex ratio 0-6 Cross-cutting 10.Full immunization Children(12-23mon) receiving 1 dose BCG,3 doses of DPT/OPV/HepB each & 1 dose measles 11.Household having access to toilet facility 12.Couple using spacing method for more than 6 months Diarrhoea 13.ORT or increased fluids for diarrhoea Pneumonia 14.Care seeking for ARI in any healthy facility

37. 39 Service delivery Woman who received 4+ ANC Skilled birth attendance Mothers who received postnatal care from a doctor/nurse/LHV/ANM/other health personnel within 2daysof delivery for their last birth Early initiation of breast feeding(<1hr) Exclusive breastfeeding for 6 months

38. 40 All India average for each indicator will be taken as a reference point States will be color coded based on: Mortality indicators, nutrition, fertility: Green- <20% of national average Yellow- 20% below & above national average Red - >20% of national average Remaining indicators: Green- >20% of national average Yellow- 20% below and above national average Red- <20% of national average

39. THANK YOU 41