Rmnch +a under headibgs indicators ,risk approach, targets and stratagies and evaluation of mch services spm park
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I now have comprehensive content from Park's textbook. Let me compile the full answer covering all four headings requested.
RMNCH+A - From Park's Textbook of Preventive and Social Medicine
What is RMNCH+A?
RMNCH+A stands for Reproductive, Maternal, Newborn, Child Health, and Adolescent health. It is India's strategic framework (launched under NHM/NRHM) that provides a continuum of care from pre-pregnancy through adolescence. The "+A" (Adolescent) was added to recognize the life-cycle approach and the importance of addressing adolescent health as a foundation for future maternal and child health outcomes.
The term Maternal and Child Health (MCH) refers to promotive, preventive, curative, and rehabilitative health care for mothers and children. It includes the sub-areas of maternal health, child health, family planning, school health, handicapped children, adolescence, and health aspects of care of children in special settings such as day care.
1. INDICATORS OF MCH SERVICES
Mortality-Based Indicators
| Indicator | Description |
|---|---|
| Maternal Mortality Ratio (MMR) | Deaths per 1,00,000 live births; India's MMR reduced from 167 (2011-13) to 113 (2016-18) per lakh live births |
| Perinatal Mortality Rate | Deaths from 28 weeks gestation to 7 days after birth |
| Neonatal Mortality Rate (NMR) | Deaths in first 28 days of life per 1,000 live births |
| Post-neonatal Mortality Rate | Deaths from 29 days to 1 year per 1,000 live births |
| Infant Mortality Rate (IMR) | Deaths under 1 year per 1,000 live births |
| 1-4 Year Mortality Rate | Deaths in 1-4 year age group |
| Under-5 Mortality Rate (U5MR) | Deaths under 5 years per 1,000 live births |
| Child Survival Rate | Complement of U5MR |
National Maternal Health Care Indicators
Estimates of maternal mortality alone are only rough indicators. Hence the following process/coverage indicators are also used (NFHS-4 data):
- Antenatal check-up coverage (at least 1 ANC, at least 4 ANCs)
- Institutional delivery rate
- Delivery by trained/skilled personnel
- Postnatal care within 48 hours
- Full immunization coverage of children
- Prevalence of anaemia in pregnant women
- Contraceptive prevalence rate (CPR)
These indicators reflect both the status of ongoing programme interventions and the situation of maternal health in the country.
Park's Textbook of Preventive and Social Medicine, p. 651-654
2. RISK APPROACH
Definition and Purpose
The Risk Approach is a managerial tool for improved MCH care. Its purpose is to provide better services for all, but with special attention to those who need them most. It involves early identification of "high-risk" cases from a large group of antenatal mothers so that skilled care can be arranged for them while appropriate care continues for all mothers.
High-Risk Cases (14 categories as per Park)
- Elderly primi (30 years and over)
- Short-statured primi (140 cm and below)
- Malpresentations - breech, transverse lie, etc.
- Antepartum haemorrhage, threatened abortion
- Pre-eclampsia and eclampsia
- Anaemia
- Twins, hydramnios
- Previous still-birth, intrauterine death, manual removal of placenta
- Previous abortion / Three or more spontaneous consecutive abortions
- Elderly grandmultiparas
- Prolonged pregnancy (14 days after expected date of delivery)
- History of previous caesarean or instrumental delivery
- Pregnancy associated with general diseases - cardiovascular disease, kidney disease, diabetes, tuberculosis, liver disease, malaria, convulsions, asthma, HIV, RTI, STI, etc.
- Treatment for infertility
Key Principles of the Risk Approach
- Inherent in this approach is maximum utilization of all resources, including non-conventional human resources: traditional birth attendants, community health workers, women's groups
- It enables determination of priority activities within the MCH programme based on "degrees" of risk
- Risk of each factor is assessed by: (a) magnitude (extent and severity); (b) treatability (responsiveness to treatment); (c) cost-effect (in terms of alleviating human suffering); (d) community attitude (social concern)
- It is a departure from traditional practices and promotes improved coverage and efficiency of MCH care at primary health care level
Park's Textbook of Preventive and Social Medicine, p. 611, 622-623
3. TARGETS AND STRATEGIES
RMNCH+A Strategies
The RMNCH+A framework works through a continuum of care across the life cycle. Key strategies include:
A. Janani Suraksha Yojana (JSY) - Conditional cash transfer to promote institutional deliveries, especially among BPL and SC/ST women.
B. Janani Shishu Suraksha Karyakram (JSSK) - Free and cashless services for pregnant women and sick newborns at public health institutions.
C. MCH Wing - Dedicated infrastructure for maternal and child health services at district hospitals (MCH Wing covers 48% of facilities).
D. Mother and Child Tracking System (MCTS) - Name-based tracking of all pregnant women for assured service delivery; ensures no woman is missed.
E. Establishment of First Referral Units (FRUs) - For emergency obstetric care, addressing the problem that despite best ANC, some women may develop complications without warning signs.
F. Risk Approach - Early detection and management of high-risk pregnancies at PHC level.
G. Attack on social and cultural factors - Illiteracy, low female literacy, nutritional deficiencies, poor environmental sanitation - through socio-economic development and community involvement.
Key Targets
| Target | Goal |
|---|---|
| MMR | Reduce to <100 per 1,00,000 live births (SDG target) |
| NMR | Single digit NMR |
| IMR | Reduce to <30 per 1,000 live births |
| U5MR | Reduce to <25 per 1,000 live births |
| ANC coverage | Minimum 4 ANCs for all pregnant women |
| Institutional delivery | >90% deliveries in institutions |
| Full immunization | >90% children fully immunized |
Strategies under Recent MCH Care Trends (Park)
- Integration of care - Conventional fragmented MCH services (antenatal, postnatal, infant care, family planning) merged into an integrated approach; all levels work as a team
- Risk approach - Early detection of high-risk mothers and children
- Manpower changes - Multi-purpose workers, Anganwadi workers, ASHAs, traditional dais (trained), voluntary workers in women's organizations
- Community participation - Active community involvement for socio-economic development
- Primary health care - Extending coverage of MCH services at PHC level to remote and rural areas
Park's Textbook of Preventive and Social Medicine, p. 623-626
4. EVALUATION OF MCH SERVICES
Principles of Evaluation
Evaluation of MCH services is done using the following indicators and methods:
A. Mortality Indicators (Outcome Measures)
| Indicator | What It Reflects |
|---|---|
| MMR | Quality of maternity services; both direct and indirect obstetric death rates are "fine measures" of quality |
| IMR / NMR | Overall effectiveness of child survival programmes |
| U5MR | Cumulative effectiveness of all child health interventions |
| Perinatal mortality rate | Quality of intrapartum care and early neonatal care |
B. Process/Coverage Indicators
- % of pregnant women receiving at least 1 ANC visit (early registration within 12 weeks)
- % receiving at least 4 ANCs (minimum standard)
- % of deliveries conducted by skilled birth attendants
- % of institutional deliveries
- % of mothers receiving postnatal care within 48 hours
- % of children fully immunized
- Contraceptive prevalence rate
- Coverage of IFA supplementation
- % of high-risk cases identified and referred
C. Input Indicators
- Availability and adequacy of MCH services at sub-centre, PHC, CHC, district hospital
- Availability of trained health workers (ANMs, ASHAs, Anganwadi workers)
- Infrastructure - FRUs, MCH wings, blood banks
- Coverage of home visits
D. RHIME (Representative Re-Sampled Routine Household Interview of Mortality with Medical Evaluation)
From year 2000, the SRS adopted RHIME - an enhanced form of "verbal autopsy" - as part of a prospective study of 1 million deaths within the SRS. It includes:
- Random re-sampling of field-work by an independent team
- Verbal autopsy methodology
- WHO's Global Burden of Disease categorization of maternal deaths (ICD-10 codes): haemorrhage, sepsis, hypertensive disorder, obstructed labour, abortion, other conditions
- Ensures comparability with WHO global estimates
E. Determinants of Maternal Mortality (Used in Evaluation)
| Medical Causes | Social Factors |
|---|---|
| Toxaemia of pregnancy | Age at childbirth and parity |
| Haemorrhage | Too close pregnancies |
| Infection/sepsis | Malnutrition, poverty, illiteracy |
| Obstructed labour | Lack of maternity services |
| Unsafe abortion | Delivery by untrained dais |
| Anaemia | Poor communications/transport |
| Associated diseases (cardiac, renal, hepatic, infectious) | Social customs, prejudices |
Park's Textbook of Preventive and Social Medicine, p. 650-655
Quick Summary Table
| Heading | Key Points |
|---|---|
| Indicators | MMR, IMR, NMR, U5MR, perinatal MR; plus ANC coverage, institutional deliveries, immunization |
| Risk Approach | Managerial tool; 14 high-risk categories; uses scoring for magnitude, treatability, cost-effect, community attitude |
| Targets & Strategies | MMR <100, IMR <30; JSY, JSSK, FRUs, MCTS, MCH Wing, risk approach, integration of care |
| Evaluation | Mortality indicators (MMR, IMR, NMR); process indicators (ANC, deliveries, immunization); RHIME method; input indicators (staffing, infrastructure) |
Source: Park's Textbook of Preventive and Social Medicine (23rd Edition), Chapter on Maternal and Child Health, pp. 611-655.
Additional dietary realquirement in pregnancy park spm
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I have sufficient content from Park's to compile a thorough answer. Let me now write the complete response based on all the material gathered.
Additional Dietary Requirements in Pregnancy
(Park's Textbook of Preventive and Social Medicine)
Why Increased Nutrition is Needed in Pregnancy
Reproduction costs energy. A pregnancy in total duration consumes approximately 60,000 kcal over and above normal metabolic requirements. Pregnancy therefore imposes considerable extra calorie and nutrient demands for several reasons:
- Foetal growth and development - building new tissues
- Expansion of maternal blood volume - physiological haemodilution
- Growth of uterus, placenta, and breasts
- Deposition of fat stores for delivery and lactation
- Weight gain - a normal healthy woman gains 9-11 kg during pregnancy (poor Indian women average only 6.5 kg)
- Child survival is correlated with birth weight, and birth weight is directly correlated to the weight gain of the mother during pregnancy
Park's Textbook of Preventive and Social Medicine, p. 615
ICMR Recommended Dietary Allowances (RDA) - Additional Requirements in Pregnancy
The following are the additional amounts needed over and above the normal requirements of a sedentary/moderately active woman:
| Nutrient | Normal Woman (Sedentary) | Additional in Pregnancy | Total in Pregnancy |
|---|---|---|---|
| Energy (Calories) | 1900-2230 kcal/day | +350 kcal/day | ~2550 kcal/day |
| Protein | 46-55 g/day | +23 g/day (1st trimester: +1.9 g; 2nd: +9.1 g; 3rd: +22.7 g) | ~78 g/day |
| Iron | 21 mg/day | +35 mg/day | 56 mg/day |
| Calcium | 600 mg/day | +400 mg/day | 1000-1200 mg/day |
| Folic Acid | 200 mcg/day | +400 mcg/day | 500-600 mcg/day |
| Vitamin A | 600 mcg RE/day | +200 mcg RE/day | 800 mcg RE/day |
| Vitamin C | 40 mg/day | +20 mg/day | 60 mg/day |
| Vitamin D | 5 mcg/day | +2.5 mcg/day | 7.5 mcg/day |
| Thiamine (B1) | 1.1 mg/day | +0.2 mg/day | 1.3 mg/day |
| Riboflavin (B2) | 1.3 mg/day | +0.3 mg/day | 1.6 mg/day |
| Niacin | 14 mg/day | +2 mg/day | 16 mg/day |
| Iodine | 150 mcg/day | +25 mcg/day | 175 mcg/day |
| Zinc | 10 mg/day | +2.5 mg/day | 12 mg/day |
Note: Lactation demands about 550 kcal/day extra (more than pregnancy).
Key Nutrient-Specific Notes
1. Energy
- Extra 350 kcal/day throughout pregnancy
- Mainly needed for foetal growth and deposition of maternal fat stores
- Poor nutrition = low birth weight babies = increased infant mortality
2. Protein
- The most important macronutrient for foetal tissue synthesis
- Requirements increase progressively trimester by trimester
- Sources: pulses, legumes, milk, eggs, meat, fish
3. Iron
- Most critical micronutrient in pregnancy
- 50% of pregnant women in India are anaemic (NFHS-4)
- Major aetiological factors: iron and folic acid deficiency
- Anaemia is associated with: premature births, PPH, puerperal sepsis, thromboembolic complications
- Government of India programme: 100 mg elemental iron + 500 mcg folic acid daily for 100 days through ANC clinics, PHCs and sub-centres
- If maternal iron stores are poor (from repeated pregnancies), foetus lays down insufficient iron stores - baby appears normal at birth but lacks stores needed for rapid growth in first year of life
4. Calcium
- Essential for foetal bone and tooth development
- Deficiency leads to demineralization of maternal bones
- Sources: milk, dairy products, green leafy vegetables, ragi (finger millet)
5. Folic Acid
- Critical in the first trimester (periconceptional period)
- Prevents Neural Tube Defects (NTDs) - anencephaly, spina bifida
- 400 mcg folic acid should be started before conception and continued through first trimester
- Combined with iron in government supplementation programme (500 mcg folic acid + 100 mg iron)
6. Vitamin A
- Required for foetal eye development and immune function
- Capsules of Vitamin A and D supplied free at MCH centres
- Caution: excessive Vitamin A (>10,000 IU/day) is teratogenic
7. Iodine
- Deficiency causes cretinism, deaf-mutism, mental retardation in the foetus
- Use of iodized salt mandatory
- Universal iodization of salt is the preventive strategy
8. Vitamin D
- Needed for calcium absorption
- Sources: sunlight, fortified foods, fish liver oils
- Deficiency leads to neonatal rickets and hypocalcaemia
Practical Dietary Advice in Pregnancy (Park)
A balanced and adequate diet is of utmost importance during pregnancy and lactation. Practical advice includes:
| Component | Recommendation |
|---|---|
| Calories | Add one extra chapati/portion of rice + dal per day |
| Protein foods | Milk (500 ml/day), pulses, eggs, fish/meat |
| Green leafy vegetables | Daily - for iron, folic acid, calcium, vitamins |
| Fruits | For Vitamin C (enhances iron absorption) |
| Fluids | Extra fluid intake; avoids constipation |
| Avoid | Raw/undercooked meat, alcohol, tobacco, unpasteurized products |
Constipation (common in pregnancy due to progesterone effect) should be avoided by:
- Regular intake of green leafy vegetables and fruits
- Extra fluids
- Avoid castor oil/purgatives
Protection Against Nutritional Deficiencies (Antenatal Programme)
- Iron-Folic Acid (IFA) supplementation - 100 mg iron + 500 mcg folic acid daily for 100 days
- Protein supplementation - Fresh or skimmed milk provided free at some MCH centres
- Vitamin A and D capsules - Supplied free of cost
- Calcium supplementation - Encouraged through dietary counselling
- Iodine - Universal salt iodization programme
Effect of Poor Nutrition in Pregnancy
| Consequence | Mechanism |
|---|---|
| Low birth weight (<2.5 kg) | Insufficient calories and protein |
| Prematurity | Anaemia, malnutrition |
| Neural tube defects | Folic acid deficiency in periconception |
| Neonatal anaemia | Insufficient iron transfer to foetus |
| Maternal anaemia | Iron deficiency |
| Cretinism/intellectual disability | Iodine deficiency |
| Neonatal rickets | Vitamin D/calcium deficiency |
| Increased perinatal mortality | Combined nutritional deficiencies |
Key fact from Park: Women who smoke during pregnancy give birth to babies weighing on average 170 g less at term. Perinatal mortality among babies of smoking mothers is 10-40% higher than non-smokers.
Source: Park's Textbook of Preventive and Social Medicine (23rd Edition), Chapter on Maternal and Child Health - Antenatal Care, pp. 614-616.
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