RMNCH+A-RK ( Reproductive, Maternal, Newborn, Child & Adolescent health )

RMNCH+A built upon the continuum of care concept

To bring Reproductive, Maternal, Newborn, Child & Adolescent health under a broad umbrella

1. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH Dr. Rajesh Kulkarni MD,PhD P rofessor     Department of CommunIty Med ici ne J.N.Medical College, KAHER, Belagvi    KAHER University’s J.N. Medical College, Belagavi Department of Community Medicine

2. OBJECTIVES Definition of Reproductive and Child Health approach Phases and components of RCH program and in what way RCH – 1 and RCH – 2 differ ? Importance of RMNCH+A strategy , and how the RCH program was transformed into RMNCH+A ? Importance of Plus strategy and adolescent health Pillars and components of RMNCH+A through 5*5 matrix Briefing on some of the important interventions – programs related to Maternal health and Neonatal&child health Indian New Born Action Plan

3. CONTENTS INTRODUCTION RCH – 1 RCH – 2 RMNCH+A STRATEGY 5*5 MATRIX OF RMNCH+A LIST OF MINIMUM ESSENTIAL COMMODITIES PUBLIC PRIVATE PARTNERSHIPS FOR MATERNAL HEALTH INTERVENTIONS UNDER NHM FOCUSSING ON NEW BORN INDIA NEWBORN ACTION PLAN

4. INTRODUCTION Reproductive and child health approach :-     “ people have the ability to reproduce and regulate their fertility, women are able to go through pregnancy and childbirth 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 diseases.”

5. PROGRAMMES RELATED TO MATERNAL AND CHILD HEALTH 1880 – Establishment of training of dais 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 Network and Family Planning Program 1956 – MCH centers become integral part of PHCS 1961 – Department of Family Planning created 1971 – MTP Act

6. 1974 – Family planning services incorporated in MCH care​ 1977 – Renaming Family Planning to Family Welfare​ 1978 – Expanded program on immunization​ 1985 – Universal Immunization Program​ 1992 – Child Survival and Safe Motherhood Program​ 1997 – RCH Program Phase -1​ 2005 – RCH Program Phase -2 2013 - RMNCH+A

7. REPRODUCTIVE AND CHILD HEALTH PROGRAMME - PHASE 1 RCH Program was launched in its first phase 1997 It integrated all ongoing programs on MCH and  focused on child survival and safe motherhood,  along with implementation of target free approach, training, information, education and communication (IEC) activities, RTI/STI clinics, facilities for safe abortions, enhanced community participation and  adolescent health and reproductive hygiene. In addition to this, the program focused on districts with high crude birth rate and low female literacy.

8. M ajor interventions under RCH – 1 were : Essential obstetric care  : including -early registration of pregnancy, provision of minimum antenatal check-ups, safe delivery & minimum of three post-natal check-ups. Emergency obstetric care  : including strengthening of FRUs. 24-Hour delivery services at PHCs/CHCs  : Additional honorarium to the staff to encourage round the clock delivery facilities at health  centres .  Medical Termination of Pregnancy  :  Aim - to reduce maternal morbidity and mortality from unsafe abortions.  Assistance from the Central Government - training of manpower, supply of MTP equipment , engaging doctors trained in MTP 

9. Control of RTI and STDs  : includes HIV and AIDS control ; collaboration with NACO.  Central Government - training of the manpower ,drug kits including disposable equipment, two laboratory technicians in each district on contract basis for testing blood, urine and RTI/STD tests.   Immunization : bringing UIP under the RCH program (1997) and now its under NHM Essential newborn care : including - resuscitation of newborn , prevention of hypothermia, exclusive breastfeeding , prevention of infections and referral of sick newborns Control of diarrheal diseases  : - low o smolarity ORS, z inc , d e worming, safe drinking water  Acute respiratory infections in infants  : - training of peripheral health workers                                                                - C otrimoxazole , drug kits

10. ​ Prevention and control of vitamin A deficiency in children :​     -  to all children under 5 years of age     - first dose (1 lakh units) given at nine months of age along with measles vaccination.      - second dose (2 lakh units) given after 9 months.      - Subsequent doses (2 lakh units each) are given at 6 months intervals up to 5 years of age     - severe malnutrition - given one additional dose of vitamin A.   Prevention and control of anemia in children  :      -6 months to 5years - receive iron supplements in liquid formulation                                    - 20 mg elemental iron and 100 mcg folic acid/day for 100                                        days/year.      - 6years to 10 years – receive 30 mg elemental iron and 250 mcg folic acid for 100 days in a year.     -Children above this age group - iron supplement in the adult dose.

11. Training of dais  : with the objective of making deliveries safe.; in EAG areas and focus districts were selected on the basis of safe delivery rates <30% Empowered Action Group (EAG)  :​ Constituted in the Ministry of Health and Family Welfare, with Union Minister for Health and Family Welfare as chairman on 20th March 2001. ​ Includes states that are perceived to be most deficient in critical Socio      demographic indices. ​ Uttar Pradesh, Bihar, Madhya Pradesh, Rajasthan, Odisha ,     Chhattisgarh, Jharkhand and  Uttarakhand  ​ these states will get  focussed  attention for different health and family welfare  programmes . District surveys – rapid household survey ​​

12. REPRODUCTIVE AND CHILD HEALTH PROGRAMME – PHASE 2 The second phase of the program started in 2005 with the following strategies : Essential obstetric care including increasing institutional deliveries and ensuring skilled attendance at delivery. Emergency obstetric care including operationalizing of FRUs to provide round-the-clock delivery services, newborn care, emergency care of sick children, safe abortion services, treatment of RTI/STI, essential laboratory services and referral services. Strengthening of referral system – funds to panchayat in RCH – 1 - To local self help groups, NGO s, Women groups – in RCH - 2

13. FIRST REFERRAL UNIT : To be able to perform the full range of FRU function, a health facility must have the following facilities :  A minimum bed strength of 20-30. But in difficult areas, as the North-East states and underserved areas of EAG states, this could initially be relaxed to 10-12 beds;  (b) A fully functional operation theatre, labour room, laboratory (c) An area earmarked and equipped for newborn care in the labour room, and in the ward (d) Blood storage facility;​ (e) 24 hour water supply and electricity supply​ (f) Arrangements for waste disposal (g) Ambulance facility

14.  Full range of family planning services including laparoscopic services; Safe abortion services; Treatment of STI/RTI; ​ The three critical criteria for FRU were - availability of surgical interventions,                                                                - newborn care and                                                                 - blood storage facility on a 24-hour basis

15. REPRODUCTIVE, MATERNAL, NEWBORN, CHILD AND ADOLESCENT HEALTH (RMNCH+A) STRATEGY, 2013 June 2012 - "Global Child Survival Call To Action : A Promise to Keep " summit in Washington, DC. More than 80 countries . To reduce child mortality to ≤ 20 child deaths per 1000 live births in every country by 2035. February 2013 - " A Strategic Approach to Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) in India" - heart of National Health Mission.

16. This program is supported by : Reproductive, maternal and child health cannot be addressed in isolation.        Adolescent girl health                  Pregnancy                 Newborn and child health

17. ​ CONTINUUM OF CARE   :  There are two dimensions of health - ​             1.Stages of life cycle                                            2. Levels of care ​ ​

18. The '  PLUS '  in the strategic approach denotes :     - Inclusion of adolescence     - Linking of maternal and child health to reproductive health and other components        (like family planning, adolescent health, HIV, gender, Pre conception and Prenatal diagnostic techniques)     - Linking of community and facility based care     - Ensuring linkages and referrals between various levels of health care system.

19. AIM : To reach the maximum number of people in the remotest corners of the country through a :- GUIDELINES AND TOOLS    1. High priority districts  : Uniform and clearly defined criteria were used to identify 184          high priority districts across all 29 states to meet the needs of previously underserved        groups, including adolescents, urban poor, and tribal populations. 2.  RMNCH + A 5x5 matrix  : identifies      -five high impact interventions across each of the thematic areas,      -five cross-cutting interventions and     -five health strengthening interventions       

20. ESSENTIAL OBSTETRIC CARE  : EARLY REGISTRATION : within 12 weeks of onset of pregnancy. MINIMUM 4 ANTENATAL CHECK-UPS :        1st visit – within 12 weeks       2nd visit – 14 to 26 weeks       3rd visit - 28 to 34 weeks       4th visit – between 36 weeks and term.  IRON AND FOLIC ACID SUPPLEMENTATION : 100 mg elemental iron and 500µg folic acid; daily for minimum 100 days; continued postpartum. CALCIUM SUPPLEMENTATION : 500mg elemental calcium and 250 IU vitamin D3 each, twice daily, from 2nd trimester to 6 months postpartum. 

21. ALBENDAZOLE IN ENDEMIC AREAS TETANUS TOXOID : 2 doses, 4 weeks apart. 1 dose if previously vaccinated within 3 years INSTITUTIONAL DELIVERIES DELIVERIES BY SKILLED BIRTH ATTENDANTS : observing 5 cleans during delivery – clean hands, clean surface, clean razor blade, clean cord and clean cord stump. BIRTH SPACING AND BIRTH TIMING :      - pregnancy avoided before 20 years and after 30 yaers of age of mother.     - birth interval at least 3 years.

22. POSTNATAL CARE : Postnatal visits by ANM at residence. 3 additional visits for low birth weight babies on 14th, 21st and 28th day. EMERGENCY OBSTETRIC CARE :     Available at FRUs for pregnant women to manage life-threatening complications. DELIVERY OF MATERNAL CARE SERVICES DELIVERY POINTS : designated as follows       - L1 = minimum 3 normal deliveries per month       - L2 = minimum 10 deliveries/month including management of complications       - L3 = minimum 20 to 50 deliveries/month including C-section

23. PUBLIC PRIVATE PARTNERSHIPS FOR MATERNAL HEALTH           JANANI SURAKSHA YOJANA Modification of National Maternity Benefit Scheme (NMBS). Safe motherhood intervention under NRHM – cash assistance to pregnant women. 100% centrally sponsored scheme – implementation in all states and union territories ; special focus on LPS. GOAL : To reduce maternal and neonatal mortality by promoting institutional deliveries among poor pregnant women. Each benefeciary registered – JSY card, MCH card, aadhar number and an Aadhar -linked bank account.

24. CATEGORIES OF STATES  :      ​ Low performing states – institutional deliveries ≤ 25% ; 8 EAG states and the states of                                           Jammu and Kashmir and Assam.​ High performing states – institutional deliveries > 25% ; for rest f the states​ ELIGIBILITY FOR FINANCIAL ASSISTANCE  : LPS – all pregnant women delivering in govt. Facilities. HPS - all BPL/SC/ST women delivering in govt. health facility. LPS and HPS – all BPL/SC/ST women delivering in accredited private health facilities. Cash assistance of ₹ 500/- per delivery to all BPL pregnant women, delivering at home, irrespective of age and parity, in both LPS and HPS states.

25. CASH ASSISTANCE UNDER JSY FOR INSTITUTIONAL DELIVERY

26. JANANI SHISHU SURAKSHA KARYAKRAM  : June 2011 – to provide all delivery related expenses in a public institution, including caesarean section. ENTITLEMENTS FOR MOTHER  : for the duration of women's stay in the facility, expected to be 3 days in case of a normal delivery and 7 days in case of a caeserean section:- Free drugs and consumables Free diagnostics Free blood wherever required  Free diet Free transport

27. ENTITLEMENTS FOR NEWBORN  : Similar services to all sick newborns till 30 days of birth and all sick infants accessing public health institutions for treatment.

28. PRADHAN MANTRI MATRU VANDANA YOJANA :​ It is implemented using the platform of ICDS. The scheme provides cash incentives for improved health and nutrition to pregnant and lactating mothers. It partly compensates for wage loss to pregnant and lactating women, both prior to and after delivery of the child.

29. RASHTRIYA BAL SWASTHYA KARYAKRAM Launched in February 2013. Includes child health screening and early intervention services through early detection and management of 4 D’s : 1)Defects at birth 2)Diseases in children 3)Deficiency conditions. 4)Development delays & Disabilities Coverage: An estimated 27 crores children in the age group of 0 – 18 years are expected to be covered across the country in a phased manner

30. Programme implementation: 1) For newborn – Facility based newborn screening at public health facilities and community based newborn screening at home through ASHAs for newborn till 6 weeks age 2) For children 6 weeks to 6 years – Anganwadi centre based screening 3) For children 6 years to 18 years – Government and government aided school based screening by dedicated mobile health teams.

31. INDIA NEWBORN ACTION PLAN In India, New born Action Plan(INAP) developed on response to the global Every New born Action Plan(ENAP),launched in June 2014. Target – Reduction of preventable new born deaths, still births and also maternal deaths through effective interventions. Goal – To attain 1.single digit neonatal mortality rate by 2030 2.single digit stillbirth rate by 2030. INAP will be implemented within the existing RMNCH+A frame work, guided by the principles of integration, equity, gender, quality of care, convergence, accountability and partnerships.

32. Its strength is built on 6 pillars of intervention packages corresponding to various life stages of new born. . a)pre conception&antenatal care b)care during labour and child birth . c)immediate new born care d)care of the healthy new born . e)care of small and sick new born. f)care beyond new born survival High coverage of these interventions can prevent almost ¾ th of new born deaths,1/3 Rd of still births and ½ of the maternal deaths by 2025

33. The interventions have been categorised as : . 1) Essential (E),to be implemented universally 2) Situational (S),implementation dependent on epidemiological context 3) Advanced (A),implementation based on health system capacity of the state/district. For all these interventions there are strategic interventions separately to each of them so that they can be implemented in a better way. Monitoring and evaluation: A comprehensive assessment of targets would be done in 2020 ,further from 2020 these . milestones will be reviewed every 5 years keeping in sync with ENAP.i e.,2025,2030, and 2035.

34. Few other programmes Vandemataram scheme : Obs & gyn specialists, nursing homes, MBBS doctors can volunteer themselves for providing sefe motherhood services. SUMAN( Surakshit Matritva Aashwasan ): 2019 expected outcome :- Zero preventable, maternal and new born deaths and high quality of maternal care delivered with dignity and respect. it was started with the motto of providing zero – cost and Zero – denial health services to all the woman and new born visiting the public health facility. LAQSHYAA programme : To improve quality of care in labour room and maternity OT s - 2017 ANAEMIA MUKT BHARAT PROGRAMME: Focus of Poshan abhiyaan till the first 3 years of child by addressing the malnutrition to decrease MMR and IMR

35. Child Health Introduction In India, an estimated 26 millions of children are born every year. C hildren (0-6 years) accounts 13% of the total population (Census 2011) I mprove child survival & addresses factors contributing to Infant & U5 mortality. Ensure critical services - available at home, through community outreach & health facilities at various levels Child Health Goals under SDG E nd preventable deaths of newborn and children U5 yrs of age NMR to at least as low as 12/1000 LB U nder-5 mortality to at least as low as 25/1000 LB 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 39

36. Causes of Child Mortality in India SRS reports (2010-13) Prematurity & low birth weight (35.9%), Pneumonia (16.9%), Birth asphyxia & birth trauma (9.9%), Other noncommunicable diseases (7.9%), Diarrhoeal diseases (6.7%) Ill defined or cause unknown (4.6%), Congenital anomalies (4.6%), Acute bacterial sepsis and severe infections (4.2%), Injuries (2.1%), Fever of unknown origin (1.7%) O ther remaining causes (5.4%). 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 40

37. Thrust area under Child Health programme Thrust Area 1 : Neonatal & Child Health Essential New born care FBNC HBNC Thrust Area 2 : Nutrition Promotion of optimal Infant and Young Child Feeding Practices (MAA) S upplementation - Vitamin A,Iron Folic Acid Mx of children with SAM National Deworming Day Thrust Area 3: Mx of Common Child hood illnesses Mx Childhood Diarrhoeal Diseases & ARI Thrust Area 4: Immunisation Routine Immunisation Polio Eradication I mproving skills of HCW S trengthening-healthcare infrastructure I nvolvement of the community-BCC 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 41

38. Schemes Facility based Newborn care NBCC,NBSU,SNCU Home based Newborn care ASHA,ANM/AWW visit (6 visits –Institutional, 7 visits- home deliveries ) Home based care for young child (HBYC) IMNCI , F- IMNCI Strengthening Facility based Paediatric Care Navjat Shishu Suraksha Karyakram Infant and Young Child Feeding Nutritional Rehabilitation Centres (NRC) Reduction in morbidity and mortality due to Acute Respiratory Infections (ARI) and Diarrhoeal Diseases Supplementation with micronutrients 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 42

39. IMNCI Integrated approach for management of common illnesses -diarrhea, ARI, malaria, measles & malnutrition. IMNCI Plus includes Skilled care at birth IMNCI including inpatient care Immunization Children are divided into 2 age categories: Young infants up to 2 mths Children 2 mths - 5 yrs Colour Coding (Severity) Pink - suggests hospital referral or admission Yellow- indicates initiation of Rx Green -calls for home management. 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 43

40. Facility-based IMNCI (F-IMNCI) Skill-building package for M0s and Nurses working in 24 x 7 PHCs, FRUs, CHCs & District Hospitals which do not have trained pediatricians. Skill-based training is given to MOs & nurses.. Those who are not trained in IMNCI will get the full package of training on F-IMNCI for 11 days Already trained in IMNCI will receive 5 days of training, on the facility-based care portion of F-IMNCI 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 44

41. Home based care for young child (HBYC) E xtension of HBNC(NHM) programme to promote evidence based interventions 4 key domains N utrition, health, childhood development & WASH ASHA will provide home visits on 3rd, 6th, 9th, 12th and 15th months P romote early initiation of breast feeding, exclusive breast feeding till 6 mths & continued breast feeding till 2nd yr of life Q uarterly home visits schedule for LBW, SNCU & NRC discharges ASHAs will be provided incentive of Rs. 250 for completion of 5 home visits (Rs. 50 per visit) 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 45

42. Strengthening Facility based Paediatric Care V ision to set up a comprehensive unit comprising of the following sub-units (DH) Pediatric OP Facility (immunization & counselling services) 2.Emergency Triage Assessment and Treatment (ETAT) Facility 3. Paediatric Inpatient Facility a) High Dependency Unit b) Pediatric Ward c) Diarrhoea Treatment Unit d) Isolation Room 4. Ancillary Facilities (eg; laboratory, imaging, pharmacy) & Auxiliary Facilities (eg; play area, Hospital kitchen) 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 46

43. Adolescent health 253 million adolescents in the age group 10-19 years in India. Requires nutrition, education, counseling, guidance to ensure their development into healthy adults. S usceptible - early & unintended pregnancy, unsafe sex leading to STI/HIV/AIDS, malnutrition, anemia overweight, alcohol, tobacco drug abuse, mental health concerns, injuries &violence . K ey determinant of India’s overall health, mortality & morbidity Investments in ARSH -delay age at marriage R educing incidence of teenage pregnancy, meeting unmet contraception need, reducing MMR, STI incidence HIV prevalence. 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 47

44. Rashtriya Kishor Swasthya Karyakram L aunched on the 7 th  of Jan14 to address the health and development needs of 10-19 yrs of age grp which is 21 % of India’s population. M ale & female, rural and urban, married and unmarried, school adolescents with special focus on marginalized and undeserved group Adolescent friendly health clinic in all hospitals Weekly Iron Folic acid supplementation (WIFS) among the school going children ,out of school girls Peer Educator (PE) programme. Menstrual Hygiene Scheme 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 48

45. Adolescent Friendly H ealth C linics (AFHC) Clinical and counselling services SRH, Nutrition, Substance abuse, Injuries & Violence , NCD & Mental Health. T rained service providers- MO, ANM and Counsellors at AFHCs at PHCs, CHCs DHs & Medical Colleges Outreach services by counsellors are carried out at schools, colleges, youth clubs (VHND) Reporting From AFHC AFHC(5 th of Every month) District District(10 th of Every month) State State (Quarterly) MoHFW 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 49

46. 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 50

47. Peer Education Programme Peer Educators ( Saathiya)  ensure peer education covering all 6 themes of RKSK P eer educators (2 boys & 2girls) are selected per village/1000 population (Cx with VHSN Committee) Each  Saathiya  forms a group of 15-20 boys or girls from their community and conducts weekly 1-2 hr participatory sessions  Saathiya  facilitates quarterly Adolescent Health Days (AHD) ‘Yuva Samwad’ & participate Adolescent Friendly Club (AFC) meetings . ASHA act as village level  Saathiya  coordinator & takes the lead & ensures peer education activities ANMs & MHW moderate the monthly AFC sessions MO I/C & Block Adolescent Health Coordinators provide Insight  Saathiya Helpline (1800-233-1250) 51

48. Weekly Iron Folic Acid Supplementation(WIFS) MoHFW launched WIFS Programme to meet high prevalence & incidence of anaemia ( adolescent girls & boys) S upervise weekly ingestion of IFA& biannual Deworming. ii. Target groups School going adolescent girls and boys-Govt/Govt-aided/municipal schools. Out of school adolescent girls . iii. Intervention IFA using a fixed day approach. Screening of target grps for mod-severe anaemia and referring Biannual de-worming IEC for improving dietary intake P rogramme covers 11.2 crore beneficiaries including 8.4 crore in-school and 2.8 crore out of school beneficiaries. 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 52

49. Monitoring- RMNCH+A (i) HMIS (ii) Web-enabled Mother and Child Tracking System (MCTS) (iii) Maternal & Child Death Review (iv) SRS,NFHS & District Level Household Survey (DLHS) (v) Survey-based Score Card using Data 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 53

50. Summary RMNCH+A built upon the continuum of care concept To bring R eproductive, Maternal, Newborn, Child & Adolescent health under a broad umbrella Provides a strong platform for delivery of services ranging from community to various level of health care system. S trong &high commitment – GOI, HCW, Community & Family needed for successful achievement of targets 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 54

51. References Park’s Textbook Of Preventive And Social Medicine 25 th edition IAPSM Textbook Of Community Medicine 1st Edition https://nhm.gov.in/index1.php?lang=1&level=1&sublinkid=794&lid=168 http://rchiips.org/nfhs https://censusindia.gov.in/vital_statistics/SRS_Report_2018/1._Contents_2018.pdf 17-05-2022 DEPT OF COMMUNITY MEDICINE JNMC KAHER 55

52. THANK YOU THANK YOU