REPRODUCTIVE AND CHILD HEALTH SERVICES
Item
- Title
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REPRODUCTIVE
AND
CHILD HEALTH SERVICES - extracted text
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REPRODUCTIVE
AND
CHILD HEALTH SERVICES
STATE FAMILY WELFARE BUREAU
DH&FWS, BANGALORE - 560 009
JULY 1998
REPRODUCTIVE
AND
CHILD HEALTH SERVICES
THE PAST
For over 30 years Family Welfare Programme was known for its rigid,
target based approach in contraceptives. The performance was
measured by the reported numbers of the four contraceptive methodsSterilisation, Intrauterine device, Oral pills and Condoms. This was
widely criticised for being a coercive approach.
The 1994 Cairo International Conference on Population and
Development (ICPD) formulated a growing International consensus that
improving reproductive health and family planning is essential to
human welfare and development.
A growing body of evidence and the Cairo consensus suggest
"Numerical method specific contraceptive target and
monetary incentives" for providers to be replaced by a broader
system of "programme performance goals" and measures
focussed on a range of reproductive health services.
The current "Target and Incentive" system gives a demographic
planning emphasis to family welfare programme (FWP) which is
antithetical to the Reproductive and Child Health (RCH) client centered
approach advocated in the GOI-ICPD country statement for the Cairo
conference. In particular emphasis on numerical targets is a major
reason for the lack of attention to the individual client needs and is
detrimental to the quality of services provided.
Family Welfare Programme to Reproductive Child Health
The paradigm shift
To date the impact of Family Welfare Programme has been measured
in terms of their contribution to increase contraceptive prevalence and
to decrease fertility. These indicators are inadequate for measuring the
impact of Reproductive Child Health Programme and therefore, new
indicators for monitoring Reproductive health services and "Service
Quality" from the perspective of the client are urgently needed.
Over the past decade there has been a clearer articulation and
definition of reproductive health as a concept and some thinking on the
ways in which Reproductive health problems should be addressed.
Against this background the major shift in the Indian Family Welfare
Programme (FWP) is that the programme is to be re-oriented
expeditiously to a Reproductive and Child Health approach (RCH). The
main objective of which would be to meet individual client health and
family planning needs and to provide high quality services.
The principal goal of a reproductive health programme is to " Reduce
unwanted fertility " safely there by responding to the needs of the
individuals for "High quality health services" as well as to the
demographic objectives.
The strategy recommends that the targets be replaced by a broad set
of performance goals and greater emphasis on "male contraceptive
methods" especially vasectomy and condoms and greater choice of
methods.
The trend of health programme should change from a "Population
Control Approach" of reducing number to an approach that is "Gender
Sensitive and Responsive" client based, addressing the reproductive
health needs of individuals, couples and families.
Reproductive Health Programmes should aim to reduce the burden
of unplanned and unwanted child bearing and related morbidity
and mortality.
_________
What is reproductive Health ?
The 1994 International Conference on Population and Development at
Cairo (ICPD) has indicated a consensus definition as a "State of
complete physical, mental and social well being and not merely the
absence of disease or infirmity in all matters relating to reproductive
system and its function and processes"
Reproductive health approach means that
People have ability to reproduce and regulate their fertility.
Women are able to go through pregnancy and child birth safely.
The outcome of pregnancy is successful in terms of maternal and
infant survival and well being and
Couples are able to have sexual relation free of the fear of
pregnancy and of contracting diseases. (Fathallah-1988)
The reproductive health approach believe that it is linked to the subject
of Reproductive rights and freedom and to women status and
empowerment. Thus it extends beyond the narrow confines of family
planning to encompass all aspects of human sexuality and reproductive
health needs during the various stages of life cycle.
Reproductive health programme is concerned with a set of
o
Specific Health Problems
o
Identifiable cluster of client groups
Distinctive goals and strategies
The programme enable clients:
To make informed choices
Receive screening
Counseling services
Education for responsible and healthy sexuality
Access services for prevention of unwanted pregnancy
Safe abortion
Maternity care and child survival
Prevention and management of reproductive morbidity.
Implementing reproductive health services means a change in the
existing culture of the programme from one that focuses on
achieving targets to one that aim at providing a range of quality
services.
Objective of RCH packages are :
1.
Meet individual client health and family planning needs.
2.
Provide high quality services.
3.
Ensure greater service coverage
4
RCH Policy
The fundamental policy change is that instead of remaining responsible
for reducing rate of population growth, reproductive health programme
would become responsible for reducing burden of unplanned and
unwanted child bearing and related morbidity and mortality.
Further the basic assumption is that improvement in service quality will
result in client satisfaction and will over long term translate into higher
contraceptive prevalence and ultimately fertility regulation. By providing
good quality services the programme will be able to achieve the
objective of not only reducing fertility but also reducing reproductive
morbidity and mortality.
New Signals
Shifting to reproductive
implementation signals. :
health
approach
implies
changing
the
Client satisfaction becomes the primary programme goal with
demographic impact a secondary though important concern.
Broadening the service package is necessary
Improving service quality becomes the top priority.
The new signals for a quiet revolution in the way the programme is
planned and managed are :
Primary goal
Priority services
:
Performance measures :
Management approach
Attitude to client
Accountability
:
While still encouraging smaller families
help Client meet their own health and
Family Planning needs.
Full range of family planning services
Quality of care, client
satisfaction,
coverage measures .
Decentralised,
client-needs
driven,
gender sensitive
Listen, assess needs and inform.
To the client and community health and
Family Welfare staff.
5
Reproductive Morbidity and Mortality :
•
One third of the total disease burden in the developing country of
women 15-44 years of age is linked to health problems
related to
pregnancy,
child
birth, abortion, HIV and
Reproductive Tract Infections (RTI's)
•
The heavy load of reproductive morbidity among Indian women
an outcome of their:
1.
Poverty
2.
Powerlessness
3.
Low social status
4.
Malnutrition
5.
Infection
6.
High fertility
7.
Lack of access to health care
•
India's maternal mortality ratio, usually estimated at 400-500 per
1,00,000 live birth is fifty times higher than that in the developed
countries.
•
In India, a small study has revealed that for every women who
dies, an estimated 16 others develop various risks.
•
Chronic and debilitating conditions such as vaginal fistulas and
uterine prolapse cause terrible suffering.
is
6
CHILD SURVIVAL AND SAFE MOTHERHOOD PROGRAMME
TO
REPRODUCTIVE AND CHILD HEALTH SERVICES
Implementation of a very important, massive and highly credible UIP
programme from 1985 to 1991 throughout the country has made a
break-through in the improvement of mother and child health services.
In spite of this, compared to developed countries, our country is still
lagging behind in respect of sensitive indicators such as infant mortality
rate and maternal mortality rate.
Looking at the perinatal mortality which contributes 50% of the infant
mortality rate and also one mother dying out of 250 pregnancies, it can
be concluded that immunization alone is not adequate and will not be
able to bring down these death rates.
Hence along with the immunization programme, a package of services
named "CHILD SURVIVAL AND SAFE MOTHERHOOD" was
implemented from April-1992 to September-1996 throughout the
country.
The main objectives of CSSM programme are:
®
®
Improvement in mother and child health
Lowering the infant deaths (0 to 1 year) child mortality (1 to 4
years) and maternal deaths.
The package of services under this programme are :
CHILDREN :
1. Essential new born care
2. Immunization (BCG, DPT, Polio and Measles)
3. Appropriate management of diarrhoea diseases
4. Appropriate management of ARI
5. Vitamin 'A' prophylaxis
MOTHERS:
1. Ante-natal care and identification of maternal
complications
2. Immunization (against Tetanus)
3. Deliveries by trained personnel
4. Prevention and treatment of anaemia
5. Promotion of Institutional deliveries
6. Provision of Emergency Obstetric Care (EmOC) services
7. Birth spacing
THE RCH PACKAGE
During 1995-96, Mandya was identified as Target Free District and the
performance was measured by certain quality indicators. Based on the
experience, from April 1996 all the districts in Karnataka have adopted
"Target Free Approach" and from September 1997 onwards as
Community Needs Assessment Approach. The implementation of
earlier isolated programmes concentrating on Family Welfare and
Mother and Child Health under National Family Welfare Programme will
now be implemented as an Integrated Reproductive and Child Health
Services which is equivalent to
*
*
*
1.
2.
Family Planning, to focus on fertility regulation,
Child Survival and Safe Motherhood Programme
Treatment of Reproductive Tract Infections and
Sexually Transmitted Infections and prevention
of AIDS
Through
Client Oriented/Mother-Friendly/ user - specific, family welfare
services, and
High quality services
The specific programmes under Reproductive and Child Health
services are
1.
Prevention and management of unwanted pregnancies
8
2.
Maternal care
a)
Ante-natal services
b)
Natal services
c)
Post-natal services
3.
Child Survival
4.
Treatment of Reproductive Tract Infections (RTI) and
Transmitted Infections (STI).
Sexually
Reducing the 'unmet need' increasing 'service coverage' and
ensuring 'quality of care' will be the focus of implementation.
The implementation guidelines of these health interventions at various
levels are detailed in the annexure.
9
FACILITIES TO BE PROVIDED IN CATEGORY "A" DISTRICTS
(Mandya, Dakshina Kannada, Kodagu)
Provision of RTI/STI drugs at 2 FRUs. (Not in the SHS Project States)
Minor civil work/repairs/maintenance provision of requisite inputs at
FRU/PHC/SCs otherwise being covered under RCH Project @ upto
Rs.10.00 lakh per District for the project period.
MTP equipments to all FRUs/CHCs not provided earlier will be given.
MTP equipments in phased manner to all PHCs.
Upto 2 Lab.Tech, for FRUs on contract basis per District for
operationalising RTI/STI screening and diagnostic interventions.
Consultant doctor at PHC as per phasing on fixed day visit basis twice
per month @ Rs.500 per visit. (Govt. Doctors can also be used for this
purpose and paid an honourariam on the same terms).
The expected work of the Consultants during visit will be to provide safe
abortion services MTP, ANC, PNC and other Family Planning and F.W.
services.
This facility will be provided upto 75% of PHC only in the initial years with
declining phasing as it is assumed that trained doctors are available at
other facilities. By the end of 5 (five) years, it is expected that with
intensive training the requirement of Consultant doctors will reduced to
25% from 75%. '
Work load norms will be atleast 5 surgical interventions or assisted
deliveries out of cases referred from periphery. Minimum of atleast 20
referred cases should be attended by the visiting doctor on each visit.
Adequate advance IEC on expected date of visit of doctor should be
announced.
io
FACILITIES TO BE PROVIDED IN CATEGORY ’'B" districts
(Hassan, Uttara Kannada, Bangalore (R), Tumkur, Chickamagalur, Shimoga, Mysore,
Kolar, Chitradurga, Belgaum, Dharwad)
Provision of RTI/STI drugs at 1 FRU each. (Not in the SHS Project States)
Minor civil work/repairs/maintenance provision of requisite inputs at
FRU/PHC/SCs otherwise being covered under RCH Project @ upto
Rs.10.00 lakh per District for the project period.
MTP equipments to all FRUs/CHCs not provided earlier.
Two Lab. Tech, at the FRU on contract basis for lab. diagnosis of STI/RTI
apart from other work.
Consultant doctor preferably lady at PHC on fixed day visit basis twice
per month @ Rs.500 per visit. (Govt, doctors can also be used for this
purpose and paid an honorarium on the same terms) as per the phasing
of MTP equipment & availability of appropriate facility.
The expected work of the Consultant during visit is to provide safe
abortion services MTP, ANC, PNC and other Family Planning and Family
Welfare services. This facility will be provided upto 75% of PHC only for
the initial years with declining phasing as it is assumed that trained
doctors are available at other facilities. By the end of 5 years, it is
expected that with the intensive training, the requirement of Consultant
doctors will be reduced to 25% from 75%.
Workload norms will be atleast 5 surgical interventions or assisted
deliveries out of cases referred from periphery. Minimum of atleast 20
referred cases should be attended by the visiting doctor on each visit.
Adequate advance IEC on expected date of visit of doctor should be
announced.
SHS Project States viz. A.P. Karnataka, Punjab & West Bengal have
already been strengthened upto Sub-District level. The average
institutional deliveries in the districts in these states range around 50%
as such, for the PHCs with low institutional deliveries (expected around
50%) the facility of the services of PHN/Staff Nurse will be provided in
50% PHCs to improve institutional delivery, ANC/PNC and screening &
referral for RTI. This facility will be limited to the 30 identified Cat B
districts in these States. They will be staying at the place of posting for
round the clock services. Rental for residence @ upto Rs.500 per annum
will be provided.
PHC drug kit for management of essential obstetric care will also be
provided to the PHCs where PHN/Staff Nurse have been appointed & are
providing round the clock services.
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FACILITIES TO BE PROVIDED iN CATEGORY "C" DISTRICTS :
(Gulbarga, Bellary, Bidar, Raichur, Bijapur, Bangalore)
Provision of EOC drugs at 2 FRU. (Not in the SHS Project States)
Minor civil works/repairs/maintenance of FRUs/PHCs/SCs at Rs.10.00 lakh per
District for the project period.
MTP equipment to all FRUs/CHCs not provided earlier.
2 Lab. Tech, for selected FRUs on contract basis per District.
In the Districts, where delivery room & residential quarters have been built under
various projects but remain unutilised, a PHN/Staff Nurse on contract basis will be
provided at PHC (for 30,000 Population). As per available information only about
25% PHCs in Category C districts can avail this facility.
All PHCs to get MTP equipment in phased manner.
Consultant doctor (preferably lady) at PHC on fixed day visit basis twice per month
@ Rs.500 per visit. (Govt, doctors can also be used for this purpose and paid an
honorarium on the same terms) as per the phasing of MTP equipment & availability
of appropriate facility.
The expected work of the Consultants during visit is to provide safe abortion
services MTP, ANC, PNC and other Family Planning and FW services. This facility
will be provided up to 75% of PHC only, as it is assumed that trained doctors are
available at other facilities. By the end of 5 years it is expected that with the
intensive training, the requirement of Consultant doctors will be reduced to 25%
from 75%.
Workload norms will be at least 5 surgical interventions or assisted deliveries out
of cases referred from periphery. Minimum of at least 20 referred cases should be
attended by the visiting doctor on each visit Adequate advance IEC on expected
date of visit of doctor should be announced.
PHC drug kit for management of essential Obst. Care and stabilisation will also be
provided to the PHCs where PHN/Staff Nurse have been appointed & are providing
round the clock services.
12
ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES
AT DIFFERENT LEVELS OF THE HEALTH SERVICES SYSTEM
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
1. Prevention and
management of
unwanted
pregnancy
1. Sexuality and
gender information
education and
counseling
No.1 as in
community level
Nos.1-6 and
2. Community
mobilization and
education for
adolescents, newly
married youth, men
and women.*
3. Community
based
contraceptive
distribution **
(through
panchayats, village
Health Guides,
Mahila Swathya
Sanghas, etc., with
follow-up)
4. Motivating
referral for
sterilization
5. Social marketing
of condoms and
oral pills through
community sources
and G.P. (Oral pills
to be distributed
through health
personnel including
GPS to women
who are starting
pills for the first
time).
6. Free supplies to
health services
* to be piloted
** Panchayats to
distribute only
condoms
2. providing * oral
contraceptives
(OCS) and
condoms.
3. Providing IUD
after screening for
contraindications.
4. Conseling and
early referral for
medical termination
of pregnancy.
5.Counseling/
management/
referral for side.
effects, method
related problems,
change of method
where indicated.
7 performing tubal
ligation by minilap
on fixed dates*
8. Performing
vasectomy.
9. Providing first
trimester medical
termination of
pregnancy upto 8
weeks (includes
MR)
First referral
Unit/District
Hospital Level
Nos. 1-11 and
12. Providing
services for
medical
termination of
pregnancy in the
first and second
trimester (upto 20
weeks) where
indicated
10. Facilities for
Copper T insertion
to post natal cases
11 Treatment
facilities for all
types of referrals
6. Add other
methods to expand
choice.
7. Providing
treatment for minor
aliments and
referral for
problems.
* Social marketing
of pills and
condoms through
HW (M&F) may be
explored by
permitting her to
retain the money.
* PHC s should
have facilities for
tubal ligation and
minit lap including
OTs and
equipments.
13
ESSENTIAL REPRODUCTIVE AND CHILD HEALTH SERVICES
AT DIFFERENT LEVELS OF THE HEALTH SERVICES SYSTEM
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
2.Maternity care
1. Early registration
of all Pregnant
Women
2. Awareness
raising for
importance of
appropriate care
during pregnancy &
identification of
danger signs
No.1-4 and
Nos.1-10 and
5. Three antenatal
contacts with
women either at
the sub-centre or at
the outreach village
sites during
immunisation/MCH
sessions.
11. Treatment of
T.B.
3. To mobilise
community support
for transport,
referral and blood
donation
6. Early detection of
high risk factors &
maternal
complications and
prompt referral
4. Counseling
education for breast
feeding nutrition,
family planning,
rest, exercise &
personal hygiene
etc.,
7. Referral of high
risk women for
institutional
delivery.
Prenatal Services
5. Early detection
and referral of high
risk pregnancies
6. Observing five
cleans or through
Social marketing of
disposable delivery
kits, Delivery
planning as to
where? when and
from whom?
12. Testing of
syphilis for high risk
group and
treatment where
necessary including
for RTI's.
First referral
Unit/District
Hospital Level
Nos. 1-12 and
13. Diagnosis and
treatment of
RTIs/STIs.
14. Weakly
clincnics for High
risk pregnancies.
8. Treatment of
malaria (facilities
including drugs to
be made available
at subcentres)
9. Treatment for TB
and follow up.
10. Preventive
measure against all
communicable
disease
* training of
laboratory
technicians,
equipment and
reagents required
* The need for I EC
support and
establishment of
first Referral
facilities
14
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
s
First referral
Unit/District
Hospital Level
Delivery Services
1. Early
Recognition of
pregnancy and its
danger signals (
rupture of
membranes of
more than 12 hours
duration, prolapse
of the cord,
hemorrhage)
Nos.1-4 and
Nos. 1-7 and
Nos. 1-9 and
5. Supervising
home delivery
8. Modified
partograph
10. Treatment of
severe sepsis
6. Prophylaxis and
treatment for
infection (except
sepsis)
9. Delivery services
11. Delivery of
referred cases
2. Conducting clean
deliveries with
delivery kits by
trained personnel.
3. Detection of
complications
referral for hospital
delivery.
7.Routine
prophylaxis for
gonococci eye
infection.
10. Repair of
episiotomy and
perennial tears
12. Treatment of
high risk cases
13. Services for
obstetrical
emergencies
anesthesia,
cesarean section,
blood transfusion
through close
relatives linkages
with blood banks
and mobile
services.
4. Providing
transport for referral
5. Referral of New
born having
difficulty in
respiration
6. Management of
Neonatal
hypothermia
15
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
First referral
Unit/District
Hospital Level
Postpartum
services
1. Breast -feeding
support.
Nos. 1-6 and
Nos. 1-8 and
Nos.1-10 and
7. Referral for
complications
9 Referral to
FRUs for
complications after
starting an LV. line
and giving initial
does of antibiotics
and oxytocin when
indicated.
11. Management of
referred cases.
2. Family Planning
counseling
3. Nutrition
counseling
4. Resuscitation for
asphyxia of the
newborn
5. Management of.
neonatal
hypothermia
6. Early recognition
of post partum
sepsis & referral
8. Giving inj.
Ergometrine after
delivery of placenta
10 . Management
of asphyxiated new
born (equipment to
be provided)
PHCs and FRUs
would require
additional
equipment and
training for
management of
asphyxiated new
boms and
hypothermia. These
include a
resuscitation bag
and mask and
radiant warmers.
16
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
First referral
Unit/District
Hospital Level
Child survival
1. Health education
for breast feeding
nutrition
immunization,
utilisation of
services, etc.,
Nos 1-6 and
Nos.1-9and
Nos.1-10 and
7. Treatment of
dehydration and
pneumonia and
referral of severe
cases.
10. Management of
referred cases
11. Handling of all
paediatric cases
including
encephalopathy.
12. Identification of
certain FRU's to
provide specialist
services and
training
2. Detection and
referral of high risk
cases such as low
birth weight,
premature babies,
babies with
asphyxis,
infections, severe
dehydration acute
respiratory
infections
(ARI).etc.,
8. First aid for
injuries etc.,
9. Closing watching
on the development
of child and
creating awareness
of cheap and
nutritious food.
3. Help during
Immunization by
ANM.
4. Help during
Vitamin 'A'
supplementation by
ANM.
5. Detection of
pneumonia and
seeking, early
medical care by
community and
treatment by ANM.
6. Treatment of
diarrhoea cases
and ARI cases
I
17
Health
Intervention
Community Level
Subcenter Level
Primary Health
Centre Level
First referral
Unit/District
Hospital Level
Management of
RTIs/STIs
1. IEC. counseling
for awareness and
prevention
No.1 and 4
Nos 1-8 and
Nos. 1-9 and
5. Identification and
referral for vaginal
discharge, lower
abdominal pain,
genital ulcers in
women, and
urethra discharge,
genital ulcers,
swelling in scrotum
or groin in men.
9. Treatment of
RTIs/STIs
10. Laboratory
diagnosis and
treatment of
RTIs/STIs
2. Condom
distribution
3. Creating
awareness about
usage of sanitary
pads by women of
reproductive period
4. Creating
awareness of about
RTI’s and Personal
hygiene
10. Syphilis testing
in antenatal women
11.Syndromic
approach to detect
and treat STD in
Antenatal post
natal and at risk
groups
6. Diagnosis of
RTI/s and STI's by
Syndrome
approach.
7. Referral of
Cases not
responding to
useval treatment.
8. Partner
notification/referral
18
THE PACKAGE OF
REPRODUCTIVE AND CHILD HEALTH SERVICES
Reproductive Child Health (RCH) can be defined as a state in which "People have
the ability to reproduce and regulate their fertility: women are able to go through
pregnancy and child birth safely, the outcome of pregnancy is successful in terms
of maternal and infant survival and well being; and couples are able to have
sexual relations free of the fear of pregnancy and contracting disease”. This
means that every couple should be able to have child when they want and, that
the pregnancy is uneventful and see, that the safe delivery services are available,
that at the end of the pregnancy the mother and the child are safe and well and
the contraceptives by choice are available to prevent pregnancy and of contracting
disease.
The essential elements of reproductive and child health services at the community
and sub-centre level are given below which will help you to understand how the
reproductive and child health services are to be provided at the community level.
The different services provided under RCH programme are :
I.
FOR THE MOTHERS
*
*
*
*
*
*
*
TT Immunization
Prevention and treatment of anaemia
Antenatal care and early identification of maternal complications
Deliveries by trained personnel
Promotion of institutional deliveries
Management of Obstetric emergencies
Birth spacing
II.
FOR THE CHILDREN
*
*
*
*
*
*
*
Essential newborn care
Exclusive breast feeding and weaning
Immunization
Appropriate management of diarrhoea
Appropriate management of ARI
Vitamin A prophylaxis
Treatment of Anaemia
19
III.
FOR ELIGIBLE COUPLES
*
*
Prevention of pregnancy
Safe abortion
IV.
RTI/STD
*
Prevention and treatment of reproductive tract and sexually
transmitted diseases
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