Question 8 - Community Medicine Professional Exam (15 Marks)

• Enumerate essential components of ANC under RMNCAH+N strategy (5 marks)
• Nutritional interventions and prophylactic measures during pregnancy (4 marks)
• Key components of essential newborn care (3 marks)
• Postnatal services to mother and newborn in first six weeks (3 marks)

PART 1: Essential Components of Antenatal Care under RMNCAH+N Strategy (5 marks)

A. Registration and Scheduling of Visits

• Early registration of all pregnancies within the first trimester (before 12 weeks); a minimum of 4 ANC visits are to be ensured.
• Schedule:
  • 1st visit: within 12 weeks - history-taking, first check-up, registration
  • 2nd visit: between 14-26 weeks
  • 3rd visit: between 28-34 weeks (medical officer review at PHC)
  • 4th visit: between 36 weeks and term

B. Clinical Examination at Each Visit

1. General examination: Height (at first visit), weight, BP, pallor/anaemia, oedema
2. Abdominal examination: Fundal height, foetal lie, presentation (after 32 weeks), foetal heart sounds
3. Breast examination
4. Per vaginal examination when indicated
5. Recording of tobacco use at every visit

C. Laboratory Investigations

• At sub-centre: Pregnancy test, haemoglobin estimation, urine for albumin and sugar, rapid malaria test
• At PHC/CHC/FRU: Blood grouping with Rh factor, VDRL/RPR, HIV testing, blood sugar, urine culture

D. Immunization

• Tetanus Toxoid (TT)/Td - 2 doses (TT-1 at first contact, TT-2 at 4 weeks after TT-1); or single booster if previously immunized

E. Identification and Referral

• Identification of high-risk pregnancies (severe anaemia, hypertension, diabetes, multiple pregnancy, previous LSCS, malpresentation)
• Identification and management of danger signs (bleeding, severe headache, blurred vision, reduced foetal movements)
• Name-based tracking of all pregnant women for assured service delivery; tracking of missed/left-out ANC cases
• Malaria prophylaxis in endemic zones as per NVBDCP guidelines
• Counselling and referral for HIV/AIDS; identification and management of RTI/STI
• Providing information on Janani Suraksha Yojana (JSY) and other scheme entitlements
• Counselling on institutional delivery, pre-birth preparedness, and complication readiness

PART 2: Nutritional Interventions and Prophylactic Measures During Pregnancy (4 marks)

A. Nutritional Interventions

• Diet counselling to increase caloric intake by +350 kcal/day in 2nd trimester and +500 kcal/day in 3rd trimester
• Encourage consumption of locally available nutrient-rich foods (green leafy vegetables, pulses, fruits, eggs)
• Counselling on adequate rest, avoidance of heavy physical labour
• Promotion of iodized salt use

B. Prophylactic Measures

1. Tetanus Toxoid immunization - 2 doses as per schedule (also protects against tetanus neonatorum)
2. Anti-malarial prophylaxis - Chloroquine weekly in endemic areas (as per NVBDCP)
3. De-worming - Single dose Albendazole 400 mg in the 2nd trimester (after 1st trimester) in areas of high worm prevalence
4. Iodine supplementation - In iodine-deficient areas
5. Vitamin A - NOT given in pregnancy (teratogenic in high doses); continued postnatally
6. Treatment of anaemia - Therapeutic IFA and injection iron sucrose for severe anaemia
7. Counselling on tobacco cessation, avoidance of alcohol and tobacco; information about dangers of second-hand smoke exposure

PART 3: Key Components of Essential Newborn Care (3 marks)

1. Resuscitation (Airway and Breathing)

• Assessment at birth: breathing, tone, colour, cry
• Newborn resuscitation using bag and mask for infants with asphyxia
• Provision of a Newborn Care Corner (NCC) in the labour room at delivery facilities

2. Prevention of Hypothermia (Warmth)

• Immediate drying of the newborn with a clean dry cloth after birth
• Delayed bathing - no bath within first 6 hours (24 hours ideal)
• Skin-to-skin contact with mother
• Kangaroo Mother Care (KMC) especially for low-birth-weight babies

3. Initiation of Breastfeeding

• Early initiation of breastfeeding within 1 hour of birth
• Colostrum feeding (thick yellow first milk) - never discarded
• Exclusive breastfeeding for 6 months

4. Prevention of Infection

• Cord care: Clean cut with sterile instrument; application of 4% chlorhexidine gel to the cord stump (in community settings)
• Eye care: Instillation of 1% tetracycline or erythromycin eye ointment (prophylaxis against ophthalmia neonatorum)
• Hand hygiene before handling the newborn
• Clean delivery practices

5. Identification and Referral of Sick Newborns

• Identification of danger signs (not feeding, fast breathing, fever, jaundice, etc.)
• Timely referral to SNCU (Special Newborn Care Unit) at district hospitals or FRU for:
  • Low birth weight babies (<2500 g)
  • Preterm babies
  • Birth asphyxia
  • Sepsis

6. Vitamin K Prophylaxis

• Injection Vitamin K 1 mg IM at birth - to prevent Haemorrhagic Disease of the Newborn (HDN)

7. Immunization at Birth

• OPV-0 (Oral Polio Vaccine) - birth dose
• Hepatitis B vaccine - birth dose
• BCG - at birth or within first 4 weeks

PART 4: Postnatal Services to Mother and Newborn During the First Six Weeks (3 marks)

A. Services to the Mother

B. Services to the Newborn

C. Other PNC Services

• Name-based tracking of missed and left-out PNC cases
• Counselling on immunization schedule and Vitamin A prophylaxis
• Infant and young child feeding (IYCF) counselling
• Counselling on STI/RTI and HIV/AIDS
• Referral for congenital abnormalities or sick newborn

Question 9 - Community Medicine Professional Exam (15 Marks)

1. Define Maternal Mortality Ratio (MMR) (2 marks)
2. Enumerate the causes of MMR (3 marks)
3. As BMOH, how will you plan to reduce MMR in your area? (6 marks)
4. What is PMSMA? (2 marks)
5. Enumerate 4 important criteria of First Referral Unit (FRU) (2 marks)

PART 1: Definition of Maternal Mortality Ratio (MMR) (2 marks)

The number of maternal deaths during a given time period per 1,00,000 live births during the same time period.

PART 2: Causes of Maternal Mortality (3 marks)

A. Direct Obstetric Causes (approx. 75-80% of maternal deaths)

Most maternal deaths occur from the 3rd trimester to the first week after birth. About 50-70% maternal deaths occur in the postpartum period; 45% in the first 24 hours after delivery.

B. Indirect Obstetric Causes (approx. 20-25%)

• Cardiac disease
• Hepatitis
• Tuberculosis
• Malaria
• Renal disease
• Anaemia (severe)
• Diabetes

C. The Three Delays Model (determinants of death)

1. Delay 1 - Delay in deciding to seek care (due to illiteracy, low socio-economic status, male dominance, cultural beliefs)
2. Delay 2 - Delay in reaching a health facility (poor transport, long distances, poor roads)
3. Delay 3 - Delay in receiving adequate care at the facility (inadequate staff, equipment, blood supply)

PART 3: Plan to Reduce MMR as Block Medical Officer of Health (BMOH) (6 marks)

A. Strengthening Antenatal Care (ANC)

• Ensure 100% registration of all pregnancies within the first trimester through ANMs, ASHAs, and Village Health and Nutrition Days (VHNDs)
• Ensure minimum 4 ANC visits for all registered pregnant women
• Name-based tracking of all pregnant women; active follow-up of missed cases
• Early identification and referral of high-risk pregnancies (severe anaemia, hypertension, multiple pregnancy, malpresentation, previous LSCS)
• Ensure supply and consumption of IFA tablets, TT immunization, calcium supplements
• Promote PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) - monthly check-ups by specialist doctors on the 9th of every month

B. Promoting Institutional Delivery

• Promote Janani Suraksha Yojana (JSY) - cash incentives for institutional delivery
• Activate and strengthen Janani Shishu Suraksha Karyakram (JSSK) - free drugs, diet, diagnostics, blood, and transport for pregnant women
• Enable 24x7 delivery services at PHCs; ensure availability of trained SBAs (Skilled Birth Attendants)
• Activate Dial 108/102 ambulance services for emergency obstetric transport - to address Delay 2

C. Strengthening Emergency Obstetric Care (EmOC)

• Operationalize First Referral Units (FRUs) at CHC level with 24x7 C-section, blood transfusion services
• Ensure trained MBBS doctors/specialists are available at FRUs for EmOC
• Set up blood storage centres at FRUs
• Training of ANMs, nurses in Skilled Birth Attendance (SBA) and active management of 3rd stage of labour (AMTSL - oxytocin 10 IU IM)
• Ensure adequate supply of magnesium sulphate (for eclampsia), oxytocin, misoprostol (for PPH), and antibiotics at all levels

D. Postnatal Care

• Ensure PNC visits on Day 0, 3, 7, and 42 for all deliveries
• Screen and treat puerperal sepsis and PPH early
• Promote family planning services to reduce unwanted pregnancies and unsafe abortions

E. Community Mobilization and IEC

• Health education through ANMs, ASHAs, AWWs about danger signs during pregnancy (bleeding, severe headache, blurred vision, convulsions, fever, reduced foetal movements)
• Mobilize Mahila Arogya Samiti (MAS) and Village Health, Sanitation and Nutrition Committees (VHSNCs) to promote institutional deliveries
• Combat socio-cultural barriers, promote girl child education

F. Monitoring and Surveillance

• Conduct Maternal Death Review (MDR) for all maternal deaths to identify causes and gaps
• Identify and address facility-level, community-level, and administrative-level gaps through MDR
• Regular monitoring of ANC registration rates, institutional delivery rates, and MMR indicators

PART 4: What is PMSMA? (2 marks)

• Launched by the Government of India in June 2016 under the National Health Mission
• Objective: To provide assured, comprehensive and quality antenatal care (free of cost) to all pregnant women on the 9th of every month at designated government health facilities

Key Features:

• Targets all pregnant women in their 2nd and 3rd trimester (gestational age > 12 weeks)
• Services provided by OBGY specialists, physicians, and radiologists (including private sector volunteers)
• Services included: Physical examination (weight, BP, abdominal examination), haemoglobin, blood sugar, urine albumin/sugar, ultrasound, syphilis testing, HIV counselling and testing
• High-risk pregnancies are identified and labelled with a red sticker on their MCP (Mother and Child Protection) card for priority follow-up
• Normal pregnancies are labelled with a green sticker
• The initiative promotes "SAHI SAMAY PAR SAHI JAANCH" (right investigation at the right time)
• Private sector specialists are encouraged to contribute at least one day per month to government facilities under PMSMA

PART 5: Four Important Criteria of First Referral Unit (FRU) (2 marks)

Additional criteria include: functioning operation theatre, availability of essential drugs and equipment for EmOC (oxytocin, magnesium sulphate, antibiotics), and linkage with a functional referral transport system.

Question 10 - Community Medicine Professional Exam (15 Marks)

• Classify illness by IMNCI + justify (1+3 = 4 marks)
• Identify risk factors (4 marks)
• Management under IMNCI (3 marks)
• Benefits from local ICDS centre (4 marks)

PART 1: IMNCI Classification and Justification (4 marks)

Classification: SEVERE PNEUMONIA (or "Very Severe Disease")

Justification:

1. Fast breathing (RR = 56/min):
   • IMNCI cut-off for fast breathing in children 12-59 months = ≥ 40 breaths/min
   • Raju's RR of 56/min is well above this threshold - confirming fast breathing
2. Lower chest indrawing:
   • This is the key sign that upgrades the classification from "Pneumonia" to "Severe Pneumonia"
   • Lower chest indrawing = the lower part of the chest wall goes IN when the child breathes IN (paradoxical movement)
   • It indicates significant respiratory distress and reduced lung compliance
   • Upper chest indrawing (or subcostal recession) is less specific; it is specifically lower chest indrawing that classifies Severe Pneumonia under IMNCI

Note: He also needs to be assessed for Severe Acute Malnutrition (SAM) (given underweight status) - classified separately under the Nutritional assessment arm of IMNCI.

PART 2: Risk Factors in This Case (4 marks)

A. Child-Related (Host) Risk Factors

1. Age (18 months): Children under 5 years are at highest risk for ARI/pneumonia due to immature immunity
2. Underweight / Malnutrition: Malnutrition severely impairs immune function, increases susceptibility to infections, and worsens prognosis; underweight children have 2-3x higher mortality from pneumonia
3. Incomplete immunization: Raju has not received all vaccines - he is at risk from measles, Hib (Haemophilus influenzae b), and pertussis - all of which can cause or complicate pneumonia. Pneumococcal vaccine (PCV) also incomplete
4. Male sex: Boys aged 12-59 months have slightly higher risk for ARI

B. Environmental / Social Risk Factors

1. Biomass fuel use (indoor air pollution): Burning of wood, cow dung, crop residue for cooking releases particulate matter (PM2.5), carbon monoxide, and other pollutants - a major modifiable risk factor for childhood pneumonia and ARI. WHO estimates biomass fuel exposure to cause ~50% of pneumonia deaths in children under 5
2. Overcrowding (single room, 5 members, no separate kitchen): Facilitates droplet transmission of respiratory pathogens; higher concentration of indoor pollutants; increases exposure to sick contacts
3. No separate kitchen: Cooking smoke fills the living space directly - compounding indoor air pollution exposure
4. Urban slum residence: Associated with poor sanitation, overcrowding, poor nutrition, limited healthcare access, and high infection density
5. Low socio-economic status: Limits access to timely healthcare, nutritious food, and clean energy sources

C. Healthcare-Related Risk Factors

1. Incomplete immunization history: Suggests delayed or missed preventive care - also a marker of poor healthcare access/utilization

PART 3: Management of Raju under IMNCI (3 marks)

Step 1: URGENT REFERRAL

• Refer URGENTLY to a hospital/FRU - this is the first and most important action
• Severe pneumonia requires inpatient management

Step 2: Pre-referral Treatment (give BEFORE referral)

• First dose of an appropriate antibiotic:
  • Injection Ampicillin 50 mg/kg IV/IM + Injection Gentamicin 7.5 mg/kg IV/IM (first-line for severe pneumonia requiring referral)
  • OR oral Amoxicillin high dose (40-45 mg/kg/day in two divided doses) as per updated WHO/IMNCI guidelines if referral is not possible
• Treat fever if present: Paracetamol 15 mg/kg/dose
• Keep child warm; do NOT give bronchodilators or expectorants
• Advise mother on danger signs during transport

Step 3: At Hospital (Inpatient Management)

• Oxygen therapy if SpO2 < 90% or central cyanosis
• Parenteral antibiotics continued (Ampicillin + Gentamicin OR Ceftriaxone for 5-7 days)
• Monitor respiratory rate, oxygen saturation, feeding ability
• Nutritional rehabilitation: Given his underweight status, initiate therapeutic feeding as per SAM guidelines if confirmed SAM; refer to NRC (Nutrition Rehabilitation Centre) if needed

Step 4: Follow-up and Preventive Actions (after discharge)

• Complete immunization schedule immediately - especially PCV, measles, pentavalent
• Nutritional counselling - promote exclusive breastfeeding (though 18 months, advise complementary feeding with continued breastfeeding)
• Counsel mother on:
  • Danger signs requiring immediate return (fast breathing, unable to feed, worsening)
  • Importance of completing full antibiotic course (5 days)
  • Improved cooking practices / switching from biomass fuel
  • Ventilation of the house
• Growth monitoring - regular weighing, catch-up growth

PART 4: How Can Raju Benefit from the Local ICDS Centre (Anganwadi)? (4 marks)

1. Supplementary Nutrition

• Raju is underweight - this is a direct indication for supplementary nutrition at the AWC
• Children 6-72 months receive 500 kcal and 12-15 g protein per day (300 days/year)
• If he has SAM (Severe Acute Malnutrition), he is entitled to 800 kcal and 20-25 g protein/day (therapeutic supplementary nutrition)
• Under revised norms: a morning snack (milk/banana/egg) + hot cooked meal at the AWC; take-home ration for children under 3 years

2. Immunization

• Raju has incomplete immunization - the AWC/Anganwadi Worker (AWW) organizes immunization sessions in coordination with ANM
• He can receive pending vaccines (PCV, measles, MMR, DPT boosters) at the AWC or village immunization session
• Immunization against 9 vaccine-preventable diseases is provided through ICDS

3. Health Check-up

• Monthly weight and height monitoring - growth chart maintained (MCP card)
• Watch over developmental milestones at 18 months (walking, talking, social skills)
• General health check-up every 3-6 months to detect disease, malnutrition
• Treatment for minor ailments (diarrhoea, ARI) at AWC level
• Deworming - Albendazole as per national deworming programme (twice a year)
• Vitamin A supplementation - dose of 200,000 IU every 6 months after 12 months of age

4. Referral Services

• Since Raju is currently ill with severe pneumonia and underweight, the AWW can:
  • Refer him to the nearest PHC/CHC/hospital for further management
  • After discharge from hospital, the AWC coordinates follow-up and ensures he gets supplementary nutrition and monitoring
  • Link with NRC (Nutrition Rehabilitation Centre) if SAM confirmed - AWW does weekly home visits for first 4 weeks after NRC discharge

5. Nutrition and Health Education (for mother)

• Counselling on:
  • Complementary feeding - appropriate foods for 18-month-old
  • Continued breastfeeding up to 2 years and beyond
  • Importance of hand washing, food hygiene
  • Danger signs in children
  • Reducing indoor air pollution - switch from biomass fuel, improve ventilation
  • Benefits of institutional care and timely immunization

6. (Future benefit) Non-formal Pre-School Education

• When Raju turns 3 years, he will be entitled to non-formal pre-school education at the AWC (Balwadi component)
• This promotes cognitive, psychosocial, and motor development
• Prepares him for formal schooling

Question 11 - Community Medicine Professional Exam (15 Marks)

1. Define maternal mortality (2 marks)
2. Enlist common causes of maternal deaths (4 marks)
3. (cut off - likely:) Mention the determinants / Three Delays model (3 marks)
4. (cut off - likely:) Role of Maternal Death Review (MDR) (3 marks)
5. (cut off - likely:) Measures to reduce maternal mortality at district level (3 marks)

PART 1: Define Maternal Mortality (2 marks)

Maternal Death (WHO Definition):

"The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but NOT from unintentional or incidental causes."

Types of Maternal Death:

• Examples: deaths from PPH, eclampsia, obstetric sepsis, obstructed labour

• Examples: cardiac disease, tuberculosis, malaria, renal disease worsened by pregnancy

Maternal Mortality Ratio (MMR):

PART 2: Common Causes of Maternal Deaths (4 marks)

A. Direct Obstetric Causes (~75-80%)

Most deaths occur 3rd trimester to first week post-delivery. ~45% of postpartum deaths occur in first 24 hours after delivery; > two-thirds in the first week.

B. Indirect Obstetric Causes (~20-25%)

• Anaemia (most common indirect cause in India)
• Cardiac disease
• Tuberculosis
• Malaria (especially falciparum)
• Viral hepatitis (particularly hepatitis E in pregnancy)
• Diabetes mellitus
• Renal disease

C. Socio-demographic Factors Contributing to Maternal Deaths in India

• Illiteracy and lack of women's empowerment
• Early marriage and teenage pregnancy
• High parity (grand multipara)
• Poverty and poor nutritional status (anaemia)
• Preference for home deliveries
• Inadequate utilisation of ANC services

PART 3: Determinants of Maternal Mortality - The Three Delays Model (3 marks)

Delay 1: Delay in Deciding to Seek Care (Community Level)

• Failure to recognise danger signs
• Lack of awareness about complications
• Low status of women; decision made by husband/elders
• Financial constraints
• Previous poor experience with health facility
• Cultural beliefs and preference for traditional birth attendants (dais)
• In Coochbehar context: Low literacy, tribal/rural population, cultural norms

Delay 2: Delay in Reaching a Health Facility (Transport Level)

• Long distance to nearest facility
• Poor road infrastructure
• Non-availability or high cost of transport
• Night-time emergencies with no transport
• In Coochbehar context: Riverine/flood-prone areas; poor connectivity in interior blocks

Delay 3: Delay in Receiving Adequate Care at the Facility (Facility Level)

• Inadequate staffing (no specialist/anaesthetist)
• Non-functional operation theatre or equipment
• Absence of blood bank / blood storage facility
• Shortage of drugs (oxytocin, magnesium sulphate)
• Poor referral coordination
• In Coochbehar context: FRUs may not be fully operational; shortage of OBGyn specialists

Addressing all three delays is the foundation of any strategy to reduce MMR at district level.

PART 4: Maternal Death Review (MDR) - Role and Process (3 marks)

Objectives of MDR:

1. To identify the medical, social, and systemic factors contributing to each maternal death
2. To identify avoidable/preventable factors (substandard care, delays, system gaps)
3. To generate recommendations for corrective action
4. To monitor the impact of interventions over time

Process of MDR:

• Every maternal death (in facility or community) must be notified within 24 hours to the District CMO/CMOH
• ASHA/ANM/AWW reports community maternal deaths

• For home/community deaths, a trained health worker conducts a verbal autopsy by interviewing family members
• Standardized verbal autopsy tools are used

• For facility deaths, the case records are reviewed by a multi-disciplinary team (Medical Officer, Nursing staff, specialist)
• Identifies substandard care, delays, and avoidable factors

• All deaths reviewed at District MDR Committee meeting (chaired by CMOH)
• Findings compiled and classified
• Recommendations issued for facility improvement, training needs, drug supply, transport

• Recommendations implemented at block and district levels
• Feedback sent back to facilities and community health workers
• Impact assessed at next review cycle

Types of Avoidable Factors Identified by MDR:

• Patient/family factors (Delay 1): Lack of awareness, late decision
• Administrative/transport factors (Delay 2): No ambulance, poor roads
• Facility/provider factors (Delay 3): Substandard care, absent staff, drug shortage

In Coochbehar scenario: Initiating systematic MDR for all recent pregnancy-related deaths would identify the predominant delays and avoidable factors specific to the district, and guide targeted interventions.

PART 5: Measures to Reduce MMR at District Level (as CMOH/District Officer) (3 marks)

A. Strengthening ANC (Addressing Delay 1)

• Universal early registration of all pregnancies (within 12 weeks) through ANMs, ASHAs, AWWs
• Minimum 4 ANC visits; high-risk pregnancy identification and targeted follow-up
• PMSMA (9th of every month) - specialist ANC for all pregnant women
• IFA, TT immunization, calcium supplementation ensured for all
• Village Health and Nutrition Days (VHND) for ANC outreach
• Health education on danger signs (PPH, convulsions, fever, bleeding)

B. Promoting Safe Institutional Delivery (Addressing Delay 1 & 2)

• Janani Suraksha Yojana (JSY): Cash incentives for institutional delivery - Rs 1400 (rural LPS) + ASHA incentive
• Janani Shishu Suraksha Karyakram (JSSK): Completely free delivery, C-section, drugs, diet, diagnostics, transport and referral at government facilities
• 102/108 Ambulance services: Free emergency obstetric transport; activate in all blocks of Coochbehar
• Strengthening 24x7 delivery services at PHCs; posting trained SBAs

C. Emergency Obstetric Care - Operationalizing FRUs (Addressing Delay 3)

• Ensure all FRUs/CHCs are fully functional with 24x7 C-section, blood transfusion
• Post OBGyn specialists and anaesthetists at district hospital and FRUs
• Training of MBBS doctors in Life Saving Anaesthetic Skills (LSAS) and obstetric management skills
• Establish blood storage centres at all FRUs
• Ensure availability of emergency obstetric drugs: oxytocin, misoprostol, magnesium sulphate, antibiotics, anti-hypertensives

D. Postpartum Surveillance

• Postnatal home visits: Day 0, 3, 7, 42
• Early detection and treatment of puerperal sepsis and PPH
• Promote SUMAN (Surakshit Matritva Aashwasan): Zero preventable maternal and newborn deaths at public health facilities

E. Surveillance, Monitoring and MDR

• Mandatory notification of every maternal death within 24 hours
• Conduct MDR for all maternal deaths: identify avoidable factors and implement corrective actions
• Monthly district MDR committee meetings; feedback to facilities
• Confidential Enquiries into Maternal Deaths (CEMD) at state level

F. Socio-Demographic Interventions (Long-term)

• Promote girl child education and delay of marriage (PCPNDT enforcement, RKSK)
• Women's empowerment through SHGs and Mahila Arogya Samitis (MAS)
• Poverty alleviation and nutrition programmes (ICDS, PM-POSHAN)
• Awareness campaigns on family planning to reduce unwanted pregnancies and unsafe abortions

Note: Since Question 11 was cut off in the image, this answer covers the most probable sub-parts based on the visible text, standard exam patterns for this topic (maternal mortality + district-level scenario), and the mark allocation (15 marks). If your question paper has different sub-parts for the cut-off portion, the above answer contains all standard components and can be selectively used.

Question 11 - Community Medicine Professional Exam (15 Marks) [MJNMCH]

1. Define maternal mortality (2 marks)
2. Enlist common causes of maternal deaths (4 marks)
3. Systemic and community level factors that may contribute (4 marks)
4. Steps to be taken by district health administration (5 marks)

PART 1: Definition of Maternal Mortality (2 marks)

"The death of a woman while pregnant or within 42 days of termination of pregnancy, irrespective of the duration and site of pregnancy, from any cause related to or aggravated by the pregnancy or its management, but NOT from unintentional or incidental causes."

Types of Maternal Death:

India's current MMR = 113 per 1,00,000 live births (2016-18). West Bengal's MMR has been higher than the national average. SDG target: < 70 by 2030.

PART 2: Common Causes of Maternal Deaths (4 marks)

A. Direct Obstetric Causes (~75-80% of maternal deaths)

B. Indirect Obstetric Causes (~20-25% of maternal deaths)

• Anaemia - most common indirect cause in India; severe anaemia (Hb < 7 g/dL) drastically reduces tolerance to haemorrhage and infection
• Cardiac disease (rheumatic heart disease is common in India)
• Viral hepatitis (especially hepatitis E - fulminant in pregnancy)
• Tuberculosis
• Malaria (falciparum malaria causes severe anaemia, hypoglycaemia, cerebral malaria)
• Diabetes mellitus
• Renal disease

PART 3: Systemic and Community Level Factors Contributing to the Problem (4 marks)

A. Community Level Factors (Delay 1 - Delay in Deciding to Seek Care)

1. Low literacy and lack of awareness - women and families cannot recognise danger signs (bleeding, convulsions, fever, reduced foetal movements)
2. Low status of women - decisions about seeking care are made by husband/in-laws; women cannot decide independently
3. Early marriage and teenage pregnancy - girls married before 18 years, immature pelvis increases risk of obstructed labour; higher risk eclampsia
4. Poverty and low socio-economic status - cannot afford transport, medicines, or private care; fear of cost at facilities
5. High parity - grand multipara women at higher risk of PPH, placenta praevia
6. Traditional practices and cultural beliefs - preference for delivery by untrained dai at home; distrust of facilities; taboos around hospital delivery
7. Poor nutritional status - widespread anaemia (iron, folate deficiency) makes women vulnerable to complications
8. Lack of birth preparedness - no arrangement for transport, blood donor, or funds during emergency
9. In Coochbehar context: Significant tribal and marginalised population, seasonal flooding, riverine terrain, limited mobility

B. Systemic / Health System Level Factors (Delay 2 & Delay 3)

1. Poor road infrastructure and long distance to nearest CHC/FRU/district hospital
2. Non-availability of emergency transport - 102/108 ambulance services not universally accessible or functional in remote blocks
3. Night-time emergencies - no transport available after dark in rural/riverine areas
4. Geographic barriers - flooding, rivers, bridges in Coochbehar making access difficult seasonally

1. Shortage of skilled human resources - absence of Obstetrician/Gynaecologist and Anaesthetist at FRUs and CHCs; over-reliance on general duty MOs
2. Non-functional FRUs - FRUs not fully operationalised for 24x7 C-section services; lack of functioning operation theatre
3. Absence of blood bank / blood storage - most peripheral facilities lack blood storage, leading to delay in managing haemorrhage
4. Drug shortages - inadequate stocks of oxytocin, misoprostol, magnesium sulphate, antibiotics, anti-hypertensives at peripheral facilities
5. Poor ANC quality - failure to identify high-risk pregnancies (anaemia, hypertension) during ANC visits
6. Inadequate postnatal monitoring - most deaths occur within 24-48 hours of delivery; inadequate postnatal supervision especially after home deliveries
7. Weak surveillance and reporting - maternal deaths in community not notified; no functional Maternal Death Review (MDR) system to identify gaps
8. Inadequate referral linkages - poor communication between sub-centre, PHC, CHC, and district hospital; no structured referral protocol

PART 4: Steps to be Taken by the District Health Administration (5 marks)

Step 1: Immediate Surveillance - Maternal Death Review (MDR)

• Mandatory notification of every maternal death (facility and community) within 24 hours to the CMOH office
• Conduct MDR (Maternal Death Review) for each recent death:
  • Facility-based MDR: case record review by multidisciplinary team
  • Community-based MDR: verbal autopsy by trained health workers
• Identify the predominant delays (1, 2, or 3) operating in Coochbehar
• District MDR Committee meets monthly; findings compiled, corrective actions issued
• Feedback sent to each facility and block health team

Step 2: Strengthen Antenatal Care (Addressing Delay 1)

• Ensure 100% ANC registration within first trimester through intensified ASHA/ANM activity
• Implement PMSMA (Pradhan Mantri Surakshit Matritva Abhiyan) - specialist ANC on the 9th of every month at all CHCs and PHCs
• Early identification of high-risk pregnancies (severe anaemia Hb < 7 g/dL, hypertension, multiple pregnancy, previous LSCS) and their name-based tracking
• Ensure complete supply of IFA tablets, calcium, and TT immunization at all sub-centres
• Village Health and Nutrition Days (VHND) every month at every AWC for ANC outreach in remote areas
• Health education on danger signs through ASHA, AWW, ANM

Step 3: Promote Institutional Delivery (Addressing Delays 1 & 2)

• Actively promote Janani Suraksha Yojana (JSY) - cash incentives for institutional delivery (Rs 1400 for rural LPS + ASHA incentive)
• Implement Janani Shishu Suraksha Karyakram (JSSK) - completely free delivery, C-section, drugs, diagnostics, diet, transport, and drop-back at all government facilities
• Activate and monitor 102 ambulance service for obstetric emergencies - specific attention to remote and flood-prone blocks of Coochbehar
• In riverine/inaccessible areas: pre-position pregnant women in waiting homes attached to PHCs before expected date of delivery

Step 4: Operationalise Emergency Obstetric Care - FRUs (Addressing Delay 3)

• Ensure all designated FRUs/CHCs are 24x7 functional for C-section and emergency obstetric care
• Post OBGyn specialists and anaesthetists at district hospital and FRUs; train MBBS doctors in Life Saving Anaesthetic Skills (LSAS) and Skilled Birth Attendance (SBA)
• Establish blood storage centres at all FRUs (critical for managing PPH)
• Ensure continuous availability of emergency obstetric drugs: oxytocin 10 IU, misoprostol 600 mcg, magnesium sulphate (for eclampsia), IV antibiotics, anti-hypertensives (labetalol, hydralazine)
• Implement Active Management of Third Stage of Labour (AMTSL) protocol at all delivery points

Step 5: Strengthen Postnatal Care

• Mandate postnatal home visits on Day 0, 3, 7, and 42 by ANMs/ASHAs for all deliveries (especially home/community deliveries)
• Early detection and treatment of PPH and puerperal sepsis in postnatal period
• SUMAN (Surakshit Matritva Aashwasan) - zero preventable deaths at public facilities; respectful maternity care

Step 6: Address Socio-Community Level Factors

• Implement Mahila Arogya Samiti (MAS) and Village Health, Sanitation and Nutrition Committees (VHSNCs) for community mobilisation
• Promote girl child education and enforce PCPNDT Act / child marriage prevention
• Engage community leaders and involve men in maternal health decision-making
• Safe abortion services - promote Medical Termination of Pregnancy (MTP) at authorised centres to reduce unsafe abortion deaths

Step 7: Inter-Sectoral Coordination

• Coordinate with WCD Department (ICDS/anganwadis) for nutrition and ANC outreach
• Coordinate with PWD for road repair and bridge maintenance in flood-affected areas before delivery season
• Engage District Collector for convergence action on poverty, female literacy (NRLM, PM-POSHAN)

Question 12 - Community Medicine Professional Exam (15 Marks) [NBMCH]

1. Define Maternal and Child Health (MCH) (2 marks)
2. National programs to reduce MMR in India (7 marks)
3. How these programs contribute to improving maternal and child health (6 marks)

PART 1: Definition of Maternal and Child Health (MCH) (2 marks)

"The promotive, preventive, curative and rehabilitative health care for mothers and children." (Park's Textbook of Preventive and Social Medicine)

• Maternal health (antenatal, intranatal, postnatal care)
• Child health (neonatal, infant, and under-5 care)
• Family planning
• School health
• Adolescent health
• Care of children with disabilities/handicapped children
• Health aspects of day care settings

Specific Objectives of MCH:

The ultimate objective of MCH services is lifelong health.

The MCH Target Population ("At Risk" Groups):

• Pregnant and nursing mothers
• Infants (0-1 year)
• Pre-school children (1-5 years)
• School-age children (5-14 years)
• Women of reproductive age (15-49 years)
• Adolescents (10-19 years)

India's MMR: 113 per 1,00,000 live births (2016-18); down from 254 in 2004-06. India's U5MR: 36 per 1000 live births (2019). SDG targets by 2030: MMR < 70; NMR ≤ 12; U5MR ≤ 25 per 1000 live births.

PART 2: National Programs to Reduce MMR in India (7 marks)

1. Janani Suraksha Yojana (JSY) - 2005

• Encouraging institutional delivery
• Focusing on institutional care for BPL families

• Cash assistance to pregnant women for institutional delivery
  • Rural Low Performing States (LPS): Rs 1400 (mother) + Rs 600 (ASHA) = Rs 2000
  • Urban LPS: Rs 1000 (mother) + Rs 400 (ASHA) = Rs 1400
  • High Performing States (HPS): Rs 700 (rural), Rs 600 (urban) - for BPL/SC/ST women
• ASHA serves as link between pregnant woman and health facility - escorts, arranges transport, and ensures ANC and PNC
• Payments made through Direct Benefit Transfer (DBT) to Aadhaar-linked bank accounts
• Impact: About 100.41 lakh pregnant women benefitted in 2018-19

2. Janani Shishu Suraksha Karyakram (JSSK) - 2011

• Absolutely free delivery including C-section at government facilities
• Free drugs and consumables
• Free diet: 3 days (normal delivery), 7 days (C-section)
• Free diagnostics (blood tests, ultrasound)
• Free blood transfusion wherever required
• Free transport: Home to institution, inter-facility referral, and drop-back home
• Extended to cover complications during ANC and PNC

• Free treatment up to 30 days after birth at government facilities

Impact: Estimated to benefit more than 12 million pregnant women annually accessing government health facilities.

3. Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) - 2016

• Targets pregnant women in 2nd and 3rd trimester (>12 weeks gestation)
• Services delivered by OBGY specialists, physicians, and radiologists (including private sector volunteers)
• Package includes: physical examination, haemoglobin, blood sugar, urine albumin/sugar, ultrasound, syphilis testing, HIV counselling
• High-risk pregnancies labelled with a RED sticker on MCP card for priority follow-up
• Normal pregnancies labelled with a GREEN sticker
• Private specialists encouraged to contribute voluntarily at government facilities

Impact: 2.20 crore ANC check-ups conducted; 11.66 lakh high-risk pregnancies identified.

4. SUMAN - Surakshit Matritva Aashwasan - 2019

• Minimum 4 ANC visits
• At least one ANC check-up by specialist in 2nd/3rd trimester
• IFA, TT, calcium supplementation
• Institutional delivery (normal and C-section) free of cost
• Skilled birth attendance at every delivery
• Free postnatal care
• Free treatment for sick newborns
• Zero denial of services; no informal payments

5. LaQshya Programme - 2017

• District Hospitals (DH), Sub-district Hospitals, high-caseload CHCs, FRUs, and Medical Colleges
• Involves: infrastructure upgrading, essential equipment, adequate HR, capacity building, adherence to clinical guidelines
• Certification system: State certification → National certification (quality benchmarking)
• 2,445 public health facilities including 193 medical colleges identified
• LaQshya portal for digitization and dashboard monitoring

6. Maternal Death Review (MDR)

• Every maternal death notified within 24 hours to CMOH
• Verbal autopsy for community deaths; case record review for facility deaths
• District MDR Committee reviews cases monthly
• Identifies avoidable factors (Three Delays)
• Generates actionable recommendations for facility improvement

7. Vandemataram Scheme

• Voluntary scheme where private OBGY specialists, maternity homes, and lady doctors volunteer to provide safe motherhood services
• Free IFA tablets, TT injections, oral pills provided to enrolled Vandemataram doctors for distribution
• High-risk cases referred to government hospitals with Vandemataram cards

8. Safe Abortion Services under MTP Act

• Medical method of abortion: Mifepristone (RU-486) + Misoprostol (up to 7 weeks/49 days of amenorrhoea) - safe under supervision
• Manual Vacuum Aspiration (MVA) at PHCs - safe and simple technique for early termination
• Reduces maternal deaths from unsafe/illegal abortions (responsible for ~8.9% maternal deaths in India)

9. Anaemia Mukt Bharat Programme (under POSHAN Abhiyaan)

• Addresses anaemia - most common indirect cause of maternal deaths
• Universal IFA supplementation for pregnant women, adolescent girls, children
• Weekly Iron and Folic Acid Supplementation (WIFS) for adolescent girls (10-19 years)
• Point-of-care testing for haemoglobin at sub-centre level

10. Village Health and Nutrition Day (VHND)

• Organized once monthly at every Anganwadi Centre
• Platform for: ANC, PNC, immunization, family planning, nutrition services, health education
• Ensures outreach to women who cannot access fixed facilities

PART 3: How These Programs Contribute to Improving Maternal and Child Health (6 marks)

A. Contribution to Maternal Health

B. Contribution to Child Health

C. Overall Contribution to the MCH Continuum

1. Preconception / Antenatal Phase (PMSMA, VHND, Anaemia Mukt Bharat, Vandemataram)
   • All women identified, registered, high-risk flagged
   • Nutritional deficiencies corrected
   • Complication readiness ensured
2. Intranatal / Delivery Phase (JSY, JSSK, LaQshya, SUMAN)
   • Maximum women delivering institutionally with skilled attendants
   • Quality intrapartum care - AMTSL, clean delivery, immediate newborn care
   • Emergency obstetric care available (C-section, blood transfusion)
3. Postnatal Phase (JSSK, SUMAN, MDR, VHND)
   • Postnatal care for mother and newborn
   • Free treatment of sick newborns
   • Monitoring and accountability through MDR
   • Family planning counselling for birth spacing

The result: India's MMR has declined from 254 (2004-06) → 178 (2010-12) → 113 (2016-18), a reduction of more than 55% in 15 years. India is on track to achieve the SDG target of MMR < 70 by 2030.

Question 13 - Community Medicine Professional Exam (15 Marks) [JMNMCH]

• First child: 9-month-old, received MR vaccine, developed difficulty in breathing + generalized rash + unconsciousness within 30 minutes → referred to district hospital
• Four other children (same session): Developed mild fever + local swelling at injection site

Part (a): Most Probable Diagnosis in the First Child + Justification (2 marks)

Diagnosis: ANAPHYLAXIS (Severe anaphylactic reaction following MR vaccination)

Justification:

The four other children with mild fever and local swelling represent common minor AEFI (expected vaccine reactions) - these are distinct from anaphylaxis and do not constitute an emergency.

Part (b): Field Level Investigation of This AEFI Case (6 marks)

1. A serious AEFI (anaphylaxis) in the first child
2. A cluster of minor AEFIs (fever + local swelling) in 4 other children from the same session

Step 1: Confirm Information and Notification

• Immediately notify the District Immunization Officer (DIO) / Chief Medical Officer of Health (CMOH) about the serious AEFI within 24 hours (as mandated by AEFI surveillance guidelines)
• Obtain the child's medical record / immunization card from PHC
• Document all details about the patient, vaccine, event, and session

Step 2: Investigate the Patient (First child)

• Detailed immunization history - previous doses received; any prior reaction to vaccines
• Past medical history - any known allergies (to food like egg, gelatin, antibiotics like neomycin), history of atopic disease (asthma, eczema), immunodeficiency
• Family history of allergic reactions or similar events
• Clinical description: exact onset time, symptoms sequence (rash → breathing difficulty → unconsciousness), treatment given, outcome

Step 3: Investigate the Vaccine

• Lot number and batch number of the MR vaccine vial used
• Expiry date - was the vaccine within its expiry?
• Cold chain check - were correct temperatures maintained? Check temperature log of ILR (Ice-lined Refrigerator); VVM (Vaccine Vial Monitor) status on the vial
• Storage conditions - was the vaccine stored correctly? Was it exposed to freezing temperatures (can damage aluminium-containing vaccines) or heat?
• Reconstitution - was the correct diluent used? Was the correct volume of diluent used? Was the diluent from the same manufacturer?
• Contamination - was any other substance (drug, fluid) accidentally mixed into the vaccine vial?
• Retain the suspect vaccine vials, diluent ampoules, used syringes/needles - seal and send to State/National Cold Chain for laboratory testing (sterility, adjuvant content, chemical composition) if vaccine defect is suspected

Step 4: Investigate the Immunization Service / Programme Errors

• Was the vaccine prepared and administered correctly? (correct dose, correct route - SC for MR, correct site - right upper arm)
• Were Auto-Disabled (AD) syringes used for each child? (to rule out contamination from reuse)
• Was injection technique correct?
• Was the vaccine given to the correct child (correct age, not contraindicated)?
• Was there a pre-screening for contraindications (immunodeficiency, previous anaphylaxis)?
• Was adrenaline available at the session site for management of anaphylaxis?
• Was the "30-minute observation period" followed after MR vaccination?

Step 5: Investigate the AEFI Cluster (4 other children)

• Case definition: fever + local swelling within 24-48 hours of vaccination
• Identify all children vaccinated in the same session - check for any more cases
• Determine if same vaccine vial and same lot number was used for all 5 children
• Check if unimmunized children in the same area have similar illness (to differentiate from coincidental events)
• Since fever and local swelling are expected common minor reactions for MR vaccine, these likely represent vaccine product-related reactions (normal immune response) rather than a programme error

Step 6: Formulate Working Hypothesis and Conclude

• Based on all findings, classify the cause:
  • If only the vaccinated children are affected + same lot → vaccine product/quality defect suspected
  • If due to faulty technique/reconstitution affecting all → immunization error-related
  • If isolated to one child with known allergy history → individual vaccine product-related
• Complete the AEFI Investigation Form (Form 6) and submit to DIO/State Immunization Officer
• Take corrective actions and recommend further action

Part (c): Preventive Measures to Avoid Such Events in Future Sessions (4 marks)

A. Pre-vaccination Screening (preventing anaphylaxis)

1. Screen for contraindications before every vaccination:
   • History of previous anaphylaxis to a vaccine dose → contraindication to further doses of that vaccine
   • Known allergy to vaccine components (gelatin, neomycin, egg for yellow fever/influenza)
   • Known immunodeficiency (live vaccines like MR/BCG contraindicated in HIV/immunocompromised children)
   • Current serious acute febrile illness → defer vaccination (not just mild fever)
2. Always ask mother about previous reactions to any vaccine before administering

B. Mandatory 30-Minute Observation Period

• All vaccinees - especially after MR/MMR vaccination - should be observed for minimum 30 minutes at the session site
• Anaphylaxis almost always occurs within 30 minutes; early detection saves lives
• This rule should be strictly enforced and documented

C. Availability and Training for Anaphylaxis Management

• Adrenaline (epinephrine) 1:1000 must be available at EVERY immunization session site
• Health workers must be trained in:
  • Recognition of anaphylaxis (urticaria + breathing difficulty + hypotension/unconsciousness)
  • Immediate management:
    1. Lay patient flat with legs elevated (unless breathing difficulty)
    2. Injection Adrenaline 0.01 mg/kg (max 0.5 mg) IM in the anterolateral thigh - first and most important step
    3. Maintain airway; oxygen if available
    4. Establish IV access; IV fluids
    5. Immediate referral to hospital
• Regular mock drills for anaphylaxis management at PHC level

D. Cold Chain and Vaccine Quality Maintenance

• Ensure strict cold chain maintenance - vaccines stored at 2-8°C (ILR); never frozen except OPV
• Check VVM (Vaccine Vial Monitor) before use - discard if at or beyond discard point
• Check expiry date before every vaccination
• Use correct diluent provided by the same manufacturer for lyophilized vaccines; never substitute
• Follow open vial policy - discard opened MR vials at end of session day

E. Injection Safety and Correct Technique

• Use Auto-Disabled (AD) syringes for each injection - never reuse syringes or needles
• Correct site and route: MR vaccine given SC in right upper arm; not IV, not IM
• Correct dose: 0.5 mL
• Correct reconstitution: Use exact volume of diluent; check for particles/discolouration

F. Reporting and Monitoring

• Report ALL AEFIs (minor and serious) to the AEFI surveillance system (AEFI reporting form)
• Track and analyse AEFI data regularly to identify patterns
• Post every session, conduct brief debriefing with vaccinators to review any adverse events

Part (d): Different Types of Reactions Observed Following Immunization (3 marks)

Type 1: Vaccine Product-Related Reaction

• An AEFI caused or precipitated by the inherent properties of the vaccine (even when correctly handled and administered)
• Examples: MR vaccine causing fever and rash (5-15% of vaccinees); DTP causing fever (up to 50%); BCG causing local ulceration and scar; anaphylaxis due to vaccine components

Type 2: Vaccine Quality Defect-Related Reaction

• Caused by a manufacturing defect in the vaccine product or its administration device
• Examples: Contaminated vaccine lot causing systemic sepsis; incorrect adjuvant concentration causing severe local reactions
• Now very rare due to Good Manufacturing Practices (GMP)

Type 3: Immunization Error-Related Reaction (formerly "Programme Error")

• Caused by inappropriate vaccine handling, prescribing or administration - preventable in nature
• Examples:
  • Reuse of syringes → transmission of bloodborne infections (HBV, HCV, HIV)
  • Wrong diluent used for reconstitution → toxic reaction
  • Vaccine given at wrong site/route (IV instead of SC) → severe systemic reaction
  • Contamination of multi-dose vials
  • Frozen vaccine (aluminium-containing vaccines) administered → severe local reaction
  • Subcutaneous BCG given IM → abscess formation

Type 4: Immunization Anxiety-Related Reaction

• Arises from anxiety about the immunization - not due to vaccine itself
• Examples:
  • Vasovagal syncope (fainting) - most common; pallor, brief loss of consciousness, rapid recovery
  • Hyperventilation → tetany, tingling
  • Mass psychogenic illness (hysteria) in older children/adolescents during school immunization campaigns
  • Typically self-limiting; patient recovers quickly when laid flat

Type 5: Coincidental Event

• An event temporally associated with vaccination but caused by something else entirely - would have occurred regardless of vaccination
• Examples: Fever from concurrent bacterial infection coinciding with vaccination; febrile convulsion from another cause on the same day as vaccination
• Establishes that not all events post-vaccination are caused BY the vaccine

Question 14 - Community Medicine Professional Exam (15 Marks) [JIMSH]

PART 1: Package of Services under RMNCAH+N (6 marks)

The RMNCAH+N Continuum of Care:

R - Reproductive Health Services

• Pre-marital counselling and pre-conception care
• Screening and management of RTI/STI
• HIV/AIDS counselling and testing (ICTC services)
• Family planning services: counselling, provision of contraceptives (condoms, OCP, IUCD, emergency contraception, sterilization)
• Safe abortion services (MTP under MTP Act)
• Prevention and management of infertility
• Prevention of gender-based violence; counselling services

M - Maternal Health Services

• Early registration within 12 weeks; minimum 4 ANC visits
• Clinical examination: weight, BP, fundal height, anaemia, foetal heart
• Lab investigations: Hb, urine albumin/sugar, blood group, Rh factor, VDRL, blood sugar, HIV
• TT immunization (2 doses / booster)
• IFA supplementation (from 12 weeks), calcium, folic acid (first trimester)
• Identification and management of high-risk pregnancies
• PMSMA (specialist ANC on 9th of every month)
• Counselling on danger signs, birth preparedness, institutional delivery, JSY

• Promotion of institutional deliveries
• Skilled birth attendance
• Active Management of Third Stage of Labour (AMTSL)
• Management of obstetric emergencies (PPH, eclampsia, sepsis) at FRUs
• C-section at FRUs/CHCs/district hospitals

• Home visits on Day 0, 3, 7, 42 (and Days 14, 21, 28 for LBW)
• Monitoring for PPH, puerperal sepsis, hypertension
• Breastfeeding support; IFA continuation (180 days post-delivery)
• Family planning counselling (LAM, IUCD insertion)

N (Newborn) - Essential Newborn Care

• Immediate drying and warmth (prevent hypothermia)
• Airway clearance and resuscitation if needed
• Early initiation of breastfeeding within 1 hour
• Cord care (chlorhexidine application)
• Eye care (1% tetracycline/erythromycin ointment)
• Injection Vitamin K (prophylaxis against HDN)
• Birth dose immunization: BCG, OPV-0, Hepatitis B
• Kangaroo Mother Care (KMC) for LBW babies
• Identification and referral of sick newborns (NBSU at CHC/FRU; SNCU at district hospital)

C - Child Health Services (0-5 years)

• Universal Immunization Programme (UIP) - full immunization schedule
• Exclusive breastfeeding for 6 months; complementary feeding from 6 months
• Growth monitoring (monthly weighing at AWC)
• Vitamin A prophylaxis (100,000 IU at 9 months; 200,000 IU every 6 months thereafter up to 5 years)
• Iron supplementation (from 6 months)
• National Deworming Programme (Albendazole twice yearly from 1-19 years)
• IMNCI strategy: integrated management of pneumonia, diarrhoea, malaria, malnutrition, measles
• Management of SAM at NRCs (Nutrition Rehabilitation Centres)
• AEFI reporting and management

A - Adolescent Health Services

• Rashtriya Kishor Swasthya Karyakram (RKSK):
  • Nutrition (WIFS - Weekly Iron Folic Acid Supplementation for 10-19 years)
  • Sexual and reproductive health counselling
  • Prevention of substance abuse
  • Mental health support
  • Prevention of injuries and violence
  • Life skills education
• Kishori Shakti Yojana (KSY): empowerment of adolescent girls
• Peer education through Adolescent Health and Wellness clubs

+N - Nutrition Services (cross-cutting)

• POSHAN Abhiyaan (National Nutrition Mission): address malnutrition in first 1000 days (conception to 2 years)
• Anaemia Mukt Bharat: IFA supplementation across all age groups
• ICDS: supplementary nutrition for children 0-6 years, pregnant and lactating women
• MAA (Mothers' Absolute Affection) programme: promote breastfeeding
• Infant and Young Child Feeding (IYCF) counselling

PART 2: Services from SUBCENTRE (ANM) - Birth to 5 Years (4 marks)

A. Immediately After Birth (Day 0 - at sub-centre/home delivery)

• Essential Newborn Care:
  • Immediate drying, warming, and stimulation
  • Clear airway; basic neonatal resuscitation if needed
  • Kangaroo Mother Care (KMC) for LBW infants
  • Cord care: clean cut + chlorhexidine 4% gel application
  • Eye prophylaxis: 1% tetracycline/erythromycin ointment
  • Injection Vitamin K 1 mg IM
• Birth dose immunizations: BCG, OPV-0, Hepatitis B (at birth)
• Early initiation of breastfeeding within 1 hour
• Weighing the newborn; recording birth weight
• Minimum 24 hours stay of mother and baby at Type B sub-centre

B. Postnatal Visits - Mother and Newborn (Birth to 6 Weeks)

• Name-based tracking of all postnatal cases; follow-up of missed PNC visits
• Referral of sick mother or sick newborn to PHC/CHC/FRU

C. Child Health Services at Sub-Centre (6 Weeks to 5 Years)

1. Immunization services as per UIP schedule (Pentavalent, PCV, OPV, MR, DPT, JE, etc.) - given at sub-centre and VHNDs
2. Growth monitoring: Monthly weighing of all infants and under-5 children; plotting on growth charts
3. Vitamin A prophylaxis: 9 months (1st dose, 1 lakh IU with MR vaccine); then 2 lakh IU every 6 months up to 5 years
4. Iron and folic acid supplementation: Liquid IFA from 6 months; syrup from 6 months-5 years
5. IMNCI assessment at each visit - check for ARI (fast breathing, chest indrawing), diarrhoea (dehydration), fever/malaria, malnutrition
6. Deworming: Albendazole 400 mg every 6 months from 12 months of age
7. AEFI monitoring and reporting
8. Referral of sick children to PHC/CHC as per IMNCI protocols
9. Counselling: breastfeeding, complementary feeding, hygiene, WASH practices

PART 3: Services from ASHA - Birth to 5 Years (5 marks)

A. At the Time of Delivery and Immediately After

• Attends home delivery and supports ANM; ensures clean delivery kit is used
• Ensures newborn receives essential newborn care (drying, warmth, breastfeeding)
• Facilitates institutional delivery - escorts pregnant woman to health facility (JSY role)
• Receives JSY incentive for institutional delivery facilitation (Rs 600 in rural LPS + transport incentive)
• Ensures birth dose vaccines (BCG, OPV-0, Hep-B) are given at delivery point

B. Postnatal Home Visits (Day 0, 3, 7, 42)

• Checks the mother for: fever (>38°C), heavy bleeding, pain/redness in perineum/breast, excessive fatigue
• Checks the newborn for danger signs (using IMNCI):
  • Not feeding / feeding poorly
  • Fever (>37.5°C) or hypothermia (<35.5°C)
  • Fast breathing (>60/min in neonates)
  • Severe chest indrawing
  • Convulsions; lethargic/unconscious
  • Skin pustules; umbilical redness/pus
• Counsels mother on:
  • Breastfeeding technique and exclusive breastfeeding for 6 months
  • Keeping the baby warm; delayed bathing (>24 hours)
  • Cord care: keep dry, no application of ash/cow dung
  • Danger signs requiring immediate care-seeking
• Ensures mother is taking IFA tablets (180 days postpartum)
• For LBW babies: additional visits on Days 14, 21, 28; promotes KMC (skin-to-skin) at home

C. Immunization Support (Birth to 5 Years)

• Maintains list of all children under 5 in her area
• Mobilizes and escorts children for immunization sessions at sub-centre and VHNDs
• Tracks defaulters and dropouts - conducts home visits to ensure full immunization
• Reports any AEFI observed in children to ANM/sub-centre
• Maintains immunization records (immunization card counterfoils); monitors immunization coverage

D. Growth Monitoring and Nutrition (Birth to 5 Years)

• Weighs children at Anganwadi Centre (AWC) monthly; helps AWW maintain growth charts
• Identifies children with faltering growth (weight not increasing) and counsels mothers
• Counsels on complementary feeding at 6 months (semi-solid foods, continued breastfeeding)
• Provides IFA syrup to children from 6 months (from her drug kit)
• Ensures severely malnourished (SAM) children are referred to NRC (Nutrition Rehabilitation Centre)
• Promotes Vitamin A supplementation schedule at AWC/immunization sessions

E. Disease Surveillance and Management (Birth to 5 Years)

• First-aid and primary medical care for minor ailments: diarrhoea (ORS and zinc from drug kit), fever (paracetamol), minor injuries
• ORS distribution for diarrhoea management; counselling on home fluids
• Identifies and refers children with suspected pneumonia, severe diarrhoea, malnutrition, measles to PHC
• Disease surveillance: reports unusual illness clusters or disease outbreaks in her village to sub-centre/PHC
• Ensures children with illness identified through IMNCI are followed up after referral

F. Health Education and Counselling

• Counsels mothers on:
  • WASH practices (hand washing, safe water, sanitation)
  • Child spacing (postpartum family planning options)
  • Danger signs in children and when to seek care
  • Benefits of ICDS (Anganwadi) services for the child
  • Vitamin A prophylaxis, deworming schedules
• Acts as a link worker between community and health system
• Organises community health meetings; participates in VHNDs