Reproductive and Child Health (RCH) Programme

Definition

"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 disease."

Background and Evolution

• Family Welfare Programme
• Universal Immunization Programme (UIP)
• Oral Rehydration Therapy (ORT)
• Child Survival and Safe Motherhood (CSSM) Programme
• Acute Respiratory Infection (ARI) Control Programme

RCH Phase-I (Launched: 15th October 1997)

1. Sexually Transmitted Diseases (STD) control
2. Reproductive Tract Infections (RTI) control

Differential Approach

Interventions in ALL Districts (RCH-I)

1. Child Survival Interventions - immunization, Vitamin A (to prevent blindness), oral rehydration therapy, prevention of deaths due to pneumonia
2. Safe Motherhood Interventions - antenatal check-up, tetanus immunization, safe delivery, anaemia control programme
3. Implementation of Target Free Approach
4. High quality training at all levels
5. IEC (Information, Education, Communication) activities
6. Specially designed RCH package for urban slums and tribal areas
7. District sub-projects under Local Capacity Enhancement
8. RTI/STD Clinics at District Hospitals (where not available)
9. Facility for safe abortions at PHCs (equipment, contractual doctors)
10. Enhanced community participation through Panchayats, Women's Groups, and NGOs
11. Adolescent health and reproductive hygiene

Interventions in Selected States/Districts (RCH-I)

• Screening and treatment of RTI/STD at sub-divisional level
• Emergency obstetric care at selected FRUs (First Referral Units) with drugs
• Essential obstetric care at PHCs (drugs + PHN/Staff Nurse)
• Additional ANM at sub-centres in weak districts for MCH care
• Improved delivery services - equipment kits, IUD insertion, ANM kits at sub-centres
• Referral transport for pregnant women during emergencies (via Panchayat)

Major Interventions Under RCH Phase-I

1. Essential Obstetric Care (EOC)

• Early registration of pregnancy (within 12-16 weeks)
• Minimum 3 antenatal check-ups (by ANM or Medical Officer) to monitor progress, detect risk/complications, enable timely referral
• Provision of safe delivery (at home or institution)
• 3 postnatal check-ups to monitor recovery and detect complications

2. Emergency Obstetric Care

• Complications are not always predictable, hence EOC is essential to prevent maternal morbidity and mortality
• Under CSSM: 1748 Referral Units identified and supported with equipment kits (Kit E to Kit P)
• Under RCH: FRUs strengthened with emergency obstetric kits, equipment, and skilled manpower on contract

3. 24-Hour Delivery Services at PHCs/CHCs

• Additional honorarium given to staff to encourage round-the-clock delivery facilities

4. Medical Termination of Pregnancy (MTP)

• Under MTP Act 1971
• Aim: reduce maternal morbidity and mortality from unsafe abortions
• Central Government support: training of manpower, MTP equipment supply, doctors trained in MTP visiting PHCs on fixed dates

5. Control of RTI and STD

• Linked to HIV/AIDS control
• Implemented in close collaboration with NACO (National AIDS Control Organization)

6. Target Free Approach

• Replaced the earlier target-based approach in family planning
• Focus shifted from numerical targets to quality of care and client needs

7. Policy Decisions (RCH-I)

• ANMs/LHVs/Staff Nurses permitted to use drugs in specific emergency situations to reduce maternal mortality
• They were also permitted to carry out certain emergency interventions when the life of the mother is at stake

RCH Phase-II (2005 onwards) - Integrated with NRHM

• RCH II (existing health and family welfare programmes)
• National Vector Borne Disease Control Programmes (malaria, filaria, kala-azar, dengue/DHF, Japanese encephalitis)
• National Leprosy Eradication Programme
• Revised National Tuberculosis Control Programme (RNTCP)
• National Programme for Control of Blindness
• Iodine Deficiency Disorder Control Programme
• Integrated Disease Surveillance Project (IDSP)

Plan of Action Under NRHM/RCH-II to Strengthen Infrastructure:

1. Creation of ASHA - Accredited Social Health Activist as a community-level health volunteer
2. Strengthening Sub-Centres - essential drugs (allopathic + AYUSH), additional ANMs, untied funds of Rs. 10,000 per annum in 18 states
3. Strengthening PHCs - 24-hour services in at least 50% PHCs (including AYUSH practitioner), standard treatment guidelines, auto-disabled syringes for immunization, 24-hour referral service, second doctor provision
4. Strengthening CHCs as First Referral Units - 24-hour FRUs with anaesthetist, Indian Public Health Standards (IPHS), Rogi Kalyan Samiti for hospital management
5. Public-Private Partnership (PPP) - to enhance availability of preventive and curative RCH services

Role of Health Worker (Male) in RCH Programme

1. Utilize eligible couple and child register for family planning; spread family planning messages
2. Distribute conventional contraceptives and oral contraceptives
3. Help prospective sterilization acceptors in obtaining services
4. Provide follow-up services to male family planning acceptors; refer cases needing physician attention to PHC/Hospital
5. Build rapport with satisfied acceptors, village leaders, ASHA, Dais
6. Educate community on MTP services availability
7. Identify and refer cases of genital sore, urethral discharge, or non-itchy rash (STI/STD) to medical officer

Summary: Evolution of RCH Programme

JSY, JSSK and Other ECH (Essential Child Health / Maternal Health) Programmes

1. JANANI SURAKSHA YOJANA (JSY)

Objectives

• Reduce maternal mortality and neonatal mortality
• Encourage delivery at health institutions
• Focus on institutional care among women from Below Poverty Line (BPL) families

Salient Features

1. 100% Centrally Sponsored Scheme
2. Integrates the benefit of cash assistance with institutional care during antenatal, delivery and immediate post-partum care (under NRHM)
3. Benefit given to all women (rural + urban) from BPL households
4. Special focus on 10 Low Performing States (LPS) (having low institutional delivery rate):
   • Uttar Pradesh, Uttarakhand, Madhya Pradesh, Jharkhand, Bihar, Rajasthan, Chhattisgarh, Odisha, Assam, and Jammu & Kashmir
5. In LPS: benefit extended up to the 3rd child if mother undergoes sterilization immediately after delivery
6. The remaining states are called High Performing States (HPS)
7. ASHA acts as the link health worker between poor pregnant women and public health institutions in LPS - responsible for institutional ANC, PNC, and escorting women to health centres

Scale of Assistance (from 2012-13 onwards)

Eligibility for Cash Assistance

• LPS: ALL women (including SC/ST families) delivering in government health centres (Sub-centre, PHC, CHC, FRU, General wards of District/State Hospitals) or accredited private institutions
• HPS: BPL women and SC/ST pregnant women delivering in Govt. health centres or accredited private institutes

Limitation of Cash Assistance

• LPS: All births delivered in government or accredited private health institutions get the benefit (no limit)
• HPS: Benefit limited to up to 2 live births only

ASHA Package Availability

• (a) Cash for referral transport - minimum Rs. 250/-
• (b) Cash incentive for delivery - minimum Rs. 200/- per delivery (paid after post-natal visit + BCG immunization of child)
• (c) Balance amount paid at the hospital itself

Additional Features

• Subsidizes cost of caesarean section and obstetric complications - up to Rs. 1500 per delivery to government institutions where government specialists are not available
• BPL women preferring home delivery in both LPS and HPS - entitled to Rs. 500 per delivery (regardless of age and birth order)
• Direct Benefit Transfer (DBT): Payments made directly into Aadhar-linked bank accounts/EFT
• 2006-07 declared as the Year for Institutional Deliveries; scope extended to urban areas of HPS; restriction of age and birth order removed in LPS
• Impact: During 2018-19, about 100.41 lakh pregnant women benefited from the scheme; since inception of NRHM, 8.55 crore women have benefited

2. JANANI-SHISHU SURAKSHA KARYAKRAM (JSSK)

Entitlements for Pregnant Women

Entitlements for Sick Newborns

• Free treatment up to 30 days after birth
• Scheme subsequently extended to also cover complications during ANC, PNC, and sick infants

Impact

• Estimated to benefit more than 12 million pregnant women who access government health facilities
• Motivates women who deliver at home to opt for institutional deliveries

3. PRADHAN MANTRI SURAKSHIT MATRITVA ABHIYAN (PMSMA)

Key Features

• Provides fixed-day, free of cost, assured and quality antenatal care to ALL pregnant women in the country
• A minimum package of ANC services (including investigations and drugs) is provided on the 9th day of every month
• Involves private sector healthcare providers as volunteers to provide specialist care in government facilities
• Outcomes reported: ~2.20 crore ANC check-ups conducted by ~6,000 volunteers in more than 17,000 government facilities; more than 11.66 lakh high risk pregnancies identified across the country

4. SUMAN (Surakshit Matritva Aashwasan)

Aim

Expected Outcome

"Zero preventable maternal and newborn deaths and high quality of maternity care delivered with dignity and respect"

5. LaQshya PROGRAMME

Objective

Approach

• Improve quality of maternal and newborn care
• Provide respectful care particularly during intrapartum and postpartum periods

Implementation Components

• Infrastructure upgradation
• Ensuring availability of essential equipment
• Adequate human resources
• Capacity building of healthcare workers
• Adherence to clinical guidelines
• Improving quality processes in labour room and maternity OT

Implementation Sites

• District Hospitals (DH), Sub-District Hospitals (SDH), high case load CHCs and FRUs, and Medical Colleges
• 2,445 public health facilities (including 193 medical colleges) identified under LaQshya
• 441 labour rooms and 392 OTs achieved State certification
• 152 labour rooms and 127 OTs achieved National LaQshya certification (as of October 2019)

6. ANAEMIA MUKT BHARAT PROGRAMME (Under Poshan Abhiyaan)

Focus: The First 1000 Days

• 9 months of pregnancy + 6 months of exclusive breastfeeding + 6 months to 2 years
• Aims to address under-nutrition, increase birth weight, reduce IMR and MMR
• Extended 1 additional year (till age 3) to consolidate gains
• Children aged 3-6 years addressed through Anganwadi Centres (AWCs)

7. VANDEMATARAM SCHEME

• Any obstetric/gynaec specialist, maternity home, nursing home, lady doctor/MBBS doctor can volunteer for safe motherhood services
• Enrolled doctors display the 'Vandemataram logo' at their clinic
• IFA tablets, oral pills, TT injections provided free by District Medical Officers to Vandemataram doctors/clinics for distribution to beneficiaries
• Complex cases referred to government hospitals with a Vandemataram card

8. SAFE ABORTION SERVICES (Under RCH Phase II)

Services Provided

• Two-drug regimen: Mifepristone (RU 486) followed by Misoprostol
• Safe under supervision with appropriate counselling
• Recommended in India up to 7 weeks (49 days) of amenorrhoea in a facility with safe abortion services and blood provision

• For pregnancies up to 12 weeks

• At FRUs as per Government of India guidelines

9. MATERNAL DEATH REVIEW

• Maternal death audit (both facility-based and community-based) is an important strategy under RCH-II
• Improves quality of obstetric care and reduces MMR
• Guidelines and tools for initiating maternal death review have been formulated

10. PREGNANCY TRACKING (Under RCH-II)

• Universal screening of all pregnant women
• Providing essential and emergency obstetric care
• Focus on:
  • Focused Antenatal Care (FANC)
  • Birth preparedness and complication readiness
  • Skilled attendance at birth
  • Care within the first seven days

11. NATIONAL AMBULANCE SERVICES (Under NRHM - related to JSSK)

• Dial 108 - Emergency Response System (critical care, trauma, accident victims)
• Dial 102 - Basic patient transport, primarily for pregnant women and children (key vehicle for JSSK entitlements - free transport)
• Dial 104 - Mobile health services
• 32 states/UTs have toll-free ambulance facilities

12. NUTRITIONAL REHABILITATION CENTRES (NRCs) - Child Health Component

Three Phases of Hospital-Based Management

• At least beginning of loss of oedema
• Return of appetite
• No nasogastric tube/infusions/severe medical problems
• Alert and active child

Summary Table: Key ECH/Maternal Health Programmes

Home Based Newborn Care (HBNC)

Overview and Rationale

Service Providers

Major Objectives of HBNC

1. Provision of essential newborn care to all newborns and prevention of complications
2. Early detection and special care of preterm and low birth weight (LBW) newborns
3. Early identification of illness in the newborn and provision of appropriate care and referral
4. 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

Responsibilities of ASHA in HBNC

Pre-birth Responsibilities

1. Mobilize all pregnant mothers and ensure they receive the full package of antenatal care
2. Undertake birth planning and birth preparedness with the mother and family to ensure access to safe delivery

Core Newborn Care Skills (Home Visits)

1. Provide newborn care through a series of home visits, including:

High-Risk Baby Management

1. Assess if the baby is high-risk (preterm or LBW) using protocols, and manage through:
   • a. Increasing the number of home visits
   • b. Monitoring weight gain
   • c. Supporting and counselling the mother and family to keep the baby warm and enabling frequent, exclusive breastfeeding

Illness and Referral

1. Detect signs/symptoms of sepsis, provide first-level care and refer to an appropriate centre. If family is unable to go, ASHA ensures ANM visits the sick newborn on priority basis

Postnatal Maternal Care

1. Recognize postpartum complications in the mother and refer appropriately

Family Planning

1. Counsel the couple on family planning

Home Deliveries

1. Provide immediate newborn care in case of home deliveries or deliveries occurring on the way to the institution

Schedule of ASHA Home Visits (up to 42 days of life)

ASHA Incentive Structure for HBNC

If an ASHA completes less than 3 visits, she is not entitled to HBNC incentive.

Conditions for Incentive Payment (paid on 45th day)

• (a) Record of birth weight in the Mother and Child Protection Card
• (b) Immunization of newborn with BCG, first dose of OPV, Hepatitis B, and DPT/Pentavalent vaccine and entry in Mother and Child Protection Card
• (c) Registration of birth
• (d) Both mother and newborn are safe until the 42nd day of delivery

Related Programme: Navjat Shishu Suraksha Karyakram (NSSK)

• Trains health personnel in basic newborn care and resuscitation
• Launched to address care at birth issues:
  • Prevention of hypothermia
  • Prevention of infection
  • Early initiation of breastfeeding
  • Basic newborn resuscitation
• Objective: To have a trained health person available for basic newborn care and resuscitation at every delivery point

Related Programme: IMNCI (Integrated Management of Neonatal and Childhood Illness)

Indian Adaptations (IMNCI vs IMCI)

• a. Inclusion of 0-7 days age group in the programme
• b. Incorporating national guidelines on malaria, anaemia, Vitamin-A supplementation and immunization schedule
• c. Training begins with sick young infants up to 2 months
• d. Training time devoted equally to sick young infant and sick child
• e. Is skill-based

IMNCI Addresses:

• ARI (17%), Diarrhoea (13%), Fever (27%), Under-nutrition (43%) - the major childhood morbidities (NFHS-III data)

Community Based Newborn Screening for Birth Defects (Under RBSK)

• ASHAs are trained with simple tools - a pictorial reference book with self-explanatory pictures for identifying gross birth defects
• ASHA prioritizes children with LBW, underweight, and those from households with chronic illness (TB, HIV, haemoglobinopathy)
• Identified cases are referred to District Early Intervention Centres (DEICs) at District Hospitals

Summary: HBNC at a Glance