Note on first refferal unit for safe mothermood, spm park
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First Referral Unit (FRU) for Safe Motherhood
(Park's Textbook of Preventive and Social Medicine)
Definition
A First Referral Unit (FRU) is an existing health facility - a district hospital, sub-divisional hospital, or Community Health Centre (CHC) - that has been upgraded and declared capable of providing round-the-clock Emergency Obstetric and Newborn Care (EmONC), in addition to all routine emergencies.
Background / Historical Context
- Emergency Obstetric Care was first taken up under the Child Survival and Safe Motherhood (CSSM) Programme (1992), recognizing that obstetric complications are not always predictable.
- The concept was strengthened and made a priority under RCH Phase II (began 1st April 2005), which focused on reducing maternal and child morbidity and mortality with emphasis on rural health care.
- The two activities - operationalisation of FRUs and skilled attendance at birth - go hand in hand.
RCH Phase II: Major Strategies
Essential Obstetric Care
- Institutional delivery - 50% of PHCs and all CHCs to be made operational as 24-hour delivery centres (target: by 2010)
- Skilled attendance at delivery - ANMs/LHVs/Staff Nurses trained and permitted to use emergency drugs and carry out certain emergency interventions when the life of the mother is at stake
Emergency Obstetric Care
- Operationalizing First Referral Units (at sub-district/CHC level)
- Operationalizing PHCs and CHCs for round-the-clock delivery services
Strengthening the Referral System
- Involvement of local self-help groups, NGOs, and women groups in referral linkage
- Outsourcing transport/referral in some states
Minimum Services of a Fully Functional FRU
A fully functional FRU must provide all of the following (Park's, p. 514-596):
| # | Service |
|---|---|
| 1 | 24-hour delivery services including normal and assisted deliveries |
| 2 | Emergency obstetric care including surgical interventions like Caesarean sections |
| 3 | New-born care |
| 4 | Emergency care of sick children |
| 5 | Full range of family planning services including laparoscopic services |
| 6 | Safe abortion services |
| 7 | Treatment of STI/RTI |
| 8 | Blood storage facility |
| 9 | Essential laboratory services |
| 10 | Referral (transport) services |
Three Critical Determinants (to be "Declared" as an FRU)
There are exactly three critical determinants that make a facility eligible to be declared a FRU - all three must be available on a 24-hour basis:
- Surgical interventions (e.g., Caesarean section)
- New-born care
- Blood storage facility
Physical Infrastructure Requirements
A facility must have all of the following to perform the full range of FRU functions:
- Minimum bed strength of 20-30 beds (relaxed to 10-12 in difficult areas like North-East and EAG states)
- Fully functional operation theatre
- Fully functional labour room
- Area earmarked and equipped for newborn care in the labour room and ward
- Functional laboratory
- Blood storage facility
- 24-hour water supply and electricity
- Arrangements for waste disposal
- Ambulance facility
New Initiatives under FRU/RCH-II
- Training of MBBS doctors in Life Saving Anaesthetic Skills (LSAS) - for emergency obstetric care at sub-district/CHC level FRUs, since lack of anaesthetists is a major bottleneck
- Blood Storage Centres at FRUs - Government decided to establish blood storage centres at FRUs at sub-district levels, to ensure wider availability of safe blood for emergency obstetric and trauma care in rural areas where a full blood bank is not feasible
FRU in the Three-Tier Referral System
| Level | Facility | Role |
|---|---|---|
| Primary | Sub-centre / PHC | First point of contact; basic ANC, normal delivery, identification of high-risk cases |
| Secondary | FRU (CHC/Sub-district hospital) | Emergency obstetric care, Caesarean section, blood storage, sick newborn care - first referral point |
| Tertiary | District Hospital / Medical College | Complicated cases beyond FRU capacity |
- Sub-centres and PHCs refer high-risk pregnancies and obstetric emergencies to the FRU.
- ASHA facilitates referral transport to PHC/CHC/FRU.
- Cases beyond FRU management are further referred to the district hospital.
Significance for Safe Motherhood
- Most maternal deaths are due to the "Three Delays" - delay in seeking care, delay in reaching care, delay in receiving care. FRUs directly address the second and third delays.
- FRUs are the backbone of India's strategy to reduce Maternal Mortality Rate (MMR) and ensure access to Comprehensive Emergency Obstetric Care (CEmOC) in rural and underserved areas.
- Operationalising FRUs is considered a crucial strategy of RCH-II/NHM for saving lives of pregnant women who develop complications during pregnancy or childbirth.
Source: Park's Textbook of Preventive and Social Medicine; Government of India, Guidelines for Operationalising First Referral Units, Ministry of Health and Family Welfare, 2004.
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