Reproductive, Maternal, neonatal, child and Adolescent Health strategy launched by MoHFW, GoI.

1. RMNCH+A
strategy
Dr. Gaurav Kamboj
Junior Resident

2. “Women are not dying because
of a disease we cannot treat.
They are dying because
societies have yet to make the
decision that their lives are
worth saving.”
Mamoud Fathalla
President of the International Federation of
Gynecology and Obstetrics (FIGO),
XV World Congress, Copenhagen 1997

3. Framework
• Historical background
• Goals
• Challenges of Reproductive and Child Health- II
• Situation of Reproductive, Maternal and Child Health in
India
• Causes for Maternal and Child Deaths in India
• Rationale of RMNCH+A strategies
• Strategic RMNCH+A Interventions across life-stages
• Health System Strengthening for RMNCH+A Services
• Monitoring, information and evaluation

4. Historical background
Milestones of Family Welfare Programme
1951-56 National Family Planning Programme adopted by Govt. of India
1961-66 - Deptt. of Family Planning created in Ministry of Health
- Lippes loop introduced, Massive effort to promote IUCD
- Expansion of service facilities, spread of small family norm
1974-79 - Campaign for male sterilization
- Renaming ‘Family Planning’ to ‘Family Welfare’
1983 National Health Policy
1985 Universal Immunization Programme
1985-90 Inclusion of various programmes under MCH
1992-97 Child survival and Safe Motherhood Programme (CSSM)
1997-02 Reproductive and Child Health-I (CSSM + RTI/STI components)
2000 National Population Policy
2002 National Health Policy
2005 RCH II and NRHM (2005-2012)
2013-17 NRHM extended (NRHM + NUHM = NHM)

5. GOALS
Health outcome goals established
in the 12th Five Year Plan
• Reduction of Infant Mortality Rate (IMR) to 25 per
1,000 live births and U5MR to 33 per 1000 live
births by 2017
• Reduction in Maternal Mortality Ratio (MMR) to
100 per 100,000 live births by 2017
• Reduction in Total Fertility Rate(TFR) to 2.1 by
2017
Millennium Development Goals
27

7. Coverage targets for key RMNCH+A
interventions for 2017
• Increase facilities equipped for perinatal care
(designated as ‘delivery points’) by 100%
• Increase proportion of all births in government and
accredited private institutions at annual rate of 5.6 %
from the baseline of 61% (SRS 2010)
• Increase proportion of pregnant women receiving
antenatal care at annual rate of 6% from the baseline
of 53% (CES 2009)
GOALS

8. Coverage targets for key RMNCH+A interventions
for 2017
• Increase proportion of mothers and newborns
receiving postnatal care at annual rate of 7.5% from
the baseline of 45% (CES 2009)
• Increase proportion of deliveries conducted by SBAs
at annual rate of 2% from the baseline of 76% (CES
2009)
• Increase exclusive breast feeding rates at annual rate
of 9.6% from the baseline of 36% (CES 2009)
GOALS

9. Coverage targets for key RMNCH+A interventions
for 2017
• Reduce prevalence of under-five children who are
underweight at annual rate of 5.5% from the baseline
of 45% (NFHS 3)
• Increase coverage of three doses of DPT at annual
rate of 3.5% from the baseline of 71.5% (CES 2009)
• Increase ORS use in under-five children with
diarrhoea at annual rate of 7.2% from the baseline of
43% (CES 2009)
GOALS

10. Coverage targets for key RMNCH+A interventions
for 2017
• Reduce unmet need for family planning methods at
annual rate of 8.8% from the baseline of 21% (DLHS 3)
• Increase met need for modern family planning
methods among eligible couples at annual rate of 4.5%
from the baseline of 47% (DLHS 3)
• Reduce anaemia in adolescent girls and boys (15–19
years) at annual rate of 6% from the baseline of 56%
and 30%, respectively (NFHS 3)
GOALS

11. Coverage targets for key RMNCH+A interventions
for 2017
• Decrease the proportion of total fertility contributed
by adolescents (15–19 years) at annual rate of 3.8%
per year from the baseline of 16% (NFHS 3)
• Raise child sex ratio in the 0–6 years age group at
annual rate of 0.6% per year from the baseline of
914 (Census 2011)
GOALS

12. Current challenges of RCH II Programme
• Three components of maternal, child
and reproductive health have actually
been vertically operated in RCH.
• ‘Adolescent health’ was the weakest
pillar of our RCH program which is
now one of the key strategies of
RMNCH+A.
• Some Districts are yet to use HMIS
data to chart their progress against the target effectively.
• Timely and transparent payments for JSY are not properly
implemented
• Inadequate implementation of Strategy for fixed day static
services for family planning.

13. Situation of Reproductive, Maternal
and Child Health in India
• Maternal mortality ratio (MMR) declined from 254
(SRS 2005) to 178 (SRS 2013)
• MMR in Haryana – 146 (SRS 2013)
• IMR is 42 per 1,000 live births (SRS 2013)
• NMR is 29 per 1,000 live births (SRS 2012)
• U5MR is 52 per 1,000 live births (SRS 2012)
• TFR is 2.4 (SRS 2012) (TFR for Haryana- 2.3)
• JSY initiative resulted in a phenomenal increase in
the rate of institutional deliveries in India from 47%
(DLHS-3, 2007-08) to 73% (CES 2009).
398
327
301
254
212
178
0
50
100
150
200
250
300
350
400
450
1997-1998 1999-2001 2001-2003 2004-2006 2007-2009 2010-12
INDIA
INDIA

14. Causes OF Maternal Death in India
Haemorrhage
38%
Sepsis
11%Abortion
8%
Obstructed
labour
5%
Hypertensive
disorder
5%
others
33%
Source: Causes of maternal deaths in India, SRS 2001-03

15. Causes for under 5 child death in India
2010
pnuemonia
8%
preterm
19%
asphyxia
10%
sepsis
8%
others
2%congenital
5%
diarrhoea
1%
diarrhoea
11%
measles
3%
meningitis
2%
injuries
4%
others
12%
pnuemonia
15%
Source: WHO/CHERG 2010
Neonatal
deaths:
52%

16. Causes for Maternal and Child Deaths
in India
THE THREE DELAYS
(1) The delay in deciding to seek care
(2) The delay in reaching the
appropriate health facility
(3) The delay in receiving quality care
once inside an institution
Useful to design programmes to
address these delays.

17. Rationale of RMNCH+A strategies
• It is important to recognize that
reproductive, maternal and child health
cannot be addressed in isolation
• To provide an understanding of
comprehensive approach to improve child
survival and safe motherhood

18. Why ‘Plus’ in RMNCH+A?
1. Inclusion of adolescence as a distinct ‘life stage’ in the
overall strategy.
2. Linking of maternal and child health to reproductive
health and other components like family planning,
adolescent health, HIV, and PC&PNDT.
3. Linking of community and facility-based care as well
as referrals between various levels of health care
system to create a continuous care pathway.

19. Strategic RMNCH+A Interventions Across
Life Stages
There are two dimensions to healthcare:
(1) stages of the life cycle
(2) places where the care is provided
‘Continuum of Care’
Adolescence/
pre pregnancies
Pregnancy Birth
Newborn/
post natal
Childhood

20. Adolescent Health
Priority interventions
1. Adolescent nutrition; IFA supplementation
2. Facility-based adolescent reproductive and sexual
health services (Adolescent health clinics)
3. Information and counseling on adolescent sexual
reproductive health and other health issues
4. Menstrual hygiene
5. Preventive health
checkups

21. Adolescent Nutrition
• Nutrition education sessions to be held at
community level- quarterly Adolescent Health
Days (to coincide with Kishori Diwas in
SABLA districts)
• Screening for low BMI followed by counseling
at adolescent health clinics.
• National Iron + Initiative: Proposes to include
new age groups
• Adolescents, both in and out of school
• Women in reproductive age group

22. • Weekly iron and folic acid supplementation
scheme: It aims to cover adolescents enrolled
in class VI–XII of government, government
aided and municipal schools as well as ‘out of
school’ girls (10-19)
‘Iron ki nili goli’
Mondays will be 'Iron' days: Azad

23. IFA supplementation programme and
service delivery

24. Adolescent Friendly Health Clinics
• Sub-centre level- by ANM
• PHC - Adolescent Information and Counseling Centre
will be made functional by MO and ANM on weekly
basis.
• CHC, DH/SDH and Medical College- Adolescent
Health Clinics will provide services on a daily basis by
RMNCH+A counsellors
• Appropriate referrals for HIV testing and RTI/STI
management to ICTCs
• Provision of contraceptives

25. Information & counseling on Health Issues
• School will serve as platform to educate and counsel
adolescents on behavior risk modification.
• Under Child Health Screening & Early Intervention
Services, screening for diabetes & other NCDs is
proposed.
• Peer educators
• In order to reduce adolescent pregnancy, focused
messaging to individuals, families and communities
(including men) will be reinforced.
Life-skills-based Adolescence Education
Programme

26. Menstrual Hygiene Scheme
• Promotes better health and
hygiene among adolescent girls
(10-19 years) in rural areas
• Sanitary napkins are provided
under NRHM’s brand
‘Free days’.
These napkins are sold to
adolescent girls by ASHAs.
Rs. 6/pack

27. Preventive health checkups and screening
School Health Programme
• Bi-annual health screening for students (6–18 years)
enrolled in government and government-aided schools
for disease, deficiency and disability.
• Dedicated mobile health teams at block level.
 2 Medical Officers (MBBS / Dental / AYUSH qualified)
 2 paramedics (one ANM and any one of the following
Pharmacist/Ophthalmic Assistant/Dental assistant)
• Those need of secondary and tertiary care will be
entitled to free treatment.

28. Pregnancy and Childbirth
Priority interventions:
1. Delivery of ANC package &
tracking of high- risk preg.
2. Skilled obstetric care
3. Immediate essential newborn
care & resuscitation
4. Emergency obstetric and new born care
5. Postpartum care for mother and newborn
6. Postpartum IUCD and sterilization
7. Implementation of PC&PNDT Act

29. Preventive use of folic acid in peri-
conception period
• Enables to enter pregnancy in optimal health.
• Prevention of neural tube defects and other congenital
anomalies.
• Peri-conception phase ( 3 months before & 3 months
after conception)
• 1 pre-pregnancy visit for couples planning pregnancy
A new scheme for delaying first birth after marriage
and ensuring spacing between first and second child
was launched in May 2012 and has provision for
incentivizing ASHAs for their efforts.

30. Delivery of ANC package and tracking
of High-risk Pregnancies
• Pregnancy Testing Kits ‘Nishchay’ available at all sub-
centres and through ASHAs.
• Universal access to full antenatal package both at
community outreach and facility level.
• Mother and Child Tracking system (MCTS) enables
service providers to follow up women and programme
managers to monitor service delivery
• Universal confidential HIV screening (PPTCT Program).

31. Skilled Obstetric care and Essential
Newborn care and Resuscitation
• Delivery points
• Prioritized for allocation of resources
• Branded and positioned as quality RMNCH+A 24 X 7 centres
• Janani Suraksha Yojana (JSY)-
• Reach the unreached pregnant women who still deliver at
home
• 48 hours stay at the health facility
• Postpartum family planning methods (PPIUCD) & counselling
on exclusive breast feeding
• Direct cash payments through AADHAR enabled payment
system

32. • Janani Shishu Suraksha Karyakram (JSSK)
• Reduce out-of-pocket expenses.
• Free assured transport (ambulance service)
• Newborn Care Corners
• Established at delivery points
• Providers are trained in basic newborn care and resuscitation
through Navjaat Shishu Suraksha Karyakram (NSSK).
Skilled Obstetric care and Essential
Newborn care and Resuscitation

33. Emergency Obstetric & Newborn Care
• MCH Wing- A comprehensive package of maternal,
newborn and reproductive (family planning) services.

34. Adolescent Health
Clinic
SNCU

36. Multi skilling of Doctors
• Life Saving Anaesthetic Skills (LSAS)- 8 week
training programme of MBBS doctors
• Obstetric Management Skills including
Caesarean section (CEmOC) – 16 week training
of MBBS doctors
• Basic Emergency Obstetric Care (BEmOC) - 10
days training for Medical Officers
• Skilled Birth Attendants(SBA) - 3 week
training for ANMs/Staff Nurses.

37. Postpartum care for mother and baby
• 48 hours of stay at health facility
for institutional delivery
• At least 3 postnatal visits to
mother and 6 postnatal visits to
newborn are to be made within
six weeks of delivery
• If Home delivery: 1st visit within
24 hours of birth

38. Postpartum IUCD insertion and
sterilization
• Post-partum IUCD (PPIUCD)
insertion at district and sub-district
hospital level
• Training of M.O.s in ‘Minilap’ for
provision of Post-Partum
Sterilisation in high case load
facilities
• RMNCH counselor will ensure healthy
timing and spacing between
pregnancies and will counsel on
breast feeding and other childcare
practices.

39. Implementation of PC&PNDT Act
• Improve sex ratio at birth by regulating pre-
conception and pre-natal diagnostic techniques
misused for sex selection
• Key action:
• Dedicated PC&PNDT cells at state/district level
• Strengthening of human resources &
infrastructure at all levels
• Building community opinion against sex selective
abortion and foeticide

40. Newborn and Child care
Priority interventions
1. Home-based newborn care and prompt referral
2. Facility-based care of the sick newborn
3. Integrated management of common childhood illnesses
(diarrhoea, pneumonia and malaria)
4. Child nutrition & essential micronutrients supplementation
5. Immunisation
6. Early detection and management of defects at birth,
deficiencies, diseases and disability in children
(0–18 years)

41. Home-based newborn care and
prompt referral
• Home-based newborn care scheme (2011) provides
immediate postnatal care and essential newborn care
to all newborns up to the age of 42 days.
• Special care to pre terms and newborns by ASHAs.
• ASHA are also trained in identification of illnesses,
appropriate care and referral through home visits.

42. Facility-based care of Sick Newborns
• NBSU: 4-bedded unit providing basic level of sick
newborn care, established at CHCs/FRUs
• SNCUs at District Hospitals and tertiary care hospitals
GOAL
One SNCU in
• Each district of the country, and
• Health facilities with more than
3,000 deliveries per year
Free up to
30 days

43. Child nutrition
• Follow up of all LBW babies by ASHA and ANM
• National Iron + initiative
• Tracking of BMI of Adolescents at the AWC
• Deworming combined with
Vitamin A supplementation
during biannual rounds.
Nutritional Rehabilitation Centres (NRCs)
Will provide medical and nutritional care for
children with severe acute malnutrition (SAM)

44. Integrated management of
Common Childhood Illnesses
(pneumonia, diarrhoea and malaria)
• Availability of ORS and Zinc
ensured at all sub-centres and frontline workers
• Timely identification and prompt referral of children
with fast breathing and/or lower chest in-drawing.
• Prevention and treatment of malaria as per the
guidelines in the National Malaria Control Programme.
At community- ASHA package
First level care- IMNCI
Referral level care - F-IMNCI

45. Immunisation
• Second dose of Measles introduced
• Pentavalent vaccine, first introduced in two states
(Kerala and Tamil Nadu), is now being expanded to six
states and will eventually be scaled up to cover the
entire country.
• Coverage of vaccine beyond first year of life must be
emphasised and monitored
• Investigation report of every serious AEFI case must be
submitted within 15 days of occurrence to district
AEFI Committees

46. To strengthen routine immunization,
newer initiatives include
Provision for AD Syringes to ensure injection safety
Support for AVD from PHC to outreach sessions
Mobilization of children to immunization session sites
by ASHA
MCTS for tracking service delivery by
-Generating due lists for ANMs
-SMS alerts to beneficiaries
-Maintaining records for actual services delivered.

47. Child Health Screening and Early
Intervention Services
(Rashtriya Bal Swasthya Karyakram)
• Aims to reach 27 crore children annually in the age group
of 0-18 years
• Mobile health teams at block level
• Screening for 30 identified health conditions.
• Age group 0–6 years enrolled at AWC at least twice a year
• Age group 6-18 years in schools annually
• Free management of these children at District Early
Interventions Centres
Defects Deficiencies
Diseases
Development delays
including disabilities
Detect
4 D’s

48. Through the Reproductive Years
Priority interventions
1. Community-based promotion and delivery of
contraceptives.
2. Promotion of spacing methods (interval IUCD)
3. Sterilisation services (vasectomies, tubectomies)
4. Comprehensive abortion care
(includes MTP Act)
1. Prevention and management
of STI/RTIs

49. Community based doorstep
distribution of contraceptives
• ASHA charges a nominal amount from beneficiaries
to deliver contraceptives at the doorstep, that is,
• INR 1 for a pack of 3 condoms
• INR 1 for a cycle of OCPs
• INR 2 for a pack of emergency contraceptive pills (ECP)
• Extended to all districts
in the country

50. Promotion of spacing methods
(interval IUCD)
• Availability of IUCD CuT380 A (protection for 10 yrs)
• Incentivise ASHAs to
• Encourage the delay of the first birth in newly married couples
• Spacing of three years between the first and second childbirths.
• Ensuring IUCD services on:
• Fixed days at all sub centres and PHCs
• Regular IUCD insertion services at CHC, SDH and DH
• RMNCH counsellors at the facilities with high case load

51. Sterilization services
• Promotion of NSV for increasing
male participation.
• Emphasis on Minilap tubectomy.
• Accreditation of private providers & NGOs for service
delivery.
• Increasing the pool of trained service providers.
• Operationalising fixed day centers for sterilization is an
essential step in this direction.

52. Comprehensive abortion care
• Manual Vacuum Aspiration (MVA) facilities and
medical methods of abortion in 24 X 7 PHCs
• The comprehensive MTP services at all DH & SDH
with priority given to ‘delivery points’
• Capacity building of MOs
• Medical abortion drugs are to be
included in the essential drug list:
• Mifepristone + Misoprostol for upto 7 weeks
• Ethacridine lactate for 12 to 20 weeks

53. Management of RTIs and STIs
• Provided at all CHC, FRU and 24 X 7 PHCs.
• Syndromic management at delivery points
• Availability of colour-coded kits
• RPR testing kits for syphilis and HIV
• Service providers should be trained in syndromic
management of STI and RTI.
• To be made available across entire reproductive age
group (including adolescents, youth and adults.)

54. Health Systems Strengthening
for RMNCH+A Services
Infrastructure
a) Facility specific plans to be
prepared and implemented
as specified under IPHS
b) Assess the need for new
infrastructure, extension of
existing infrastructure on the
basis of patient load and
location of facility

55. c) Equip health facilities to support 48 hour stay of
mother and newborn.
d) Engage private facilities for family planning
services, management of sick newborns and
children, and pregnancy complications.
e) Strengthen referral mechanisms between facilities
at various levels and communities.
f) Provision for adequate
infrastructure for waste
management

56. Human Resources
• Creation of regular posts so that
contractual appointments can be
reduced and sustainable HR
structure is developed.
• Strengthening sub centres through additional human
resources:
• Accorded highest priority in this phase
• Sub centres of remote and hilly area will have 2
ANMs, 1 MPHW (M), 1 pharmacist and 1AYUSH
doctor
• Creation of a public health cadre

57. Policies on drugs, procurement system
and logistics management
• Availability of free generic drugs for minimizing out
of pocket expenses.
• Rational prescriptions and use of drugs.
• Timely procurement of drugs and consumables.
• Placing Essential drug lists (EDL) in the public
domain.
• Computerized drugs and logistic MIS.
• Central Procurement Agency for the efficient
purchase of quality medicines for distribution to
states and union territory governments.

58. Quality assurance
• Quality assurance at all levels of service delivery
• Quality certification/ accreditation of facilities and
services
 Certification for achievement of IPHS
 Comprehensive quality assurance for both infrastructure and
service delivery
 First certified by District and State Quality Assurance Cells
CENTRE
• Central Quality Supervisory Committee
STATE
• State Quality Assurance Committees
• Quality Assurance Cell
• Full time quality assessors
DISTRICT
• District Quality Assurance Committees
• Quality Circles at the District Hospital level.

59. I. Supportive supervision of health facilities
a. Engaging generalist nurse supervisors at block and
district level
b. Preparing a clear plan of supervision
c. Engaging Medical College faculty for supportive
supervision of District Hospitals
d. Preparing integrated guidelines and checklists for
supportive supervision
I. Supportive supervision of frontline workers
• Potential supervisors of frontline workers include
LHVs, ASHA supervisors, ICDS supervisors and
AYUSH doctors

60. Community participation
• Engage Village Health Sanitation
and Nutrition Committees and
Rogi Kalyan Samiti members
• Utilize the Village Health and Nutrition Days as a
platform for assured and predictable package of
outreach services
• Social audit: Centred around activities like:
• Maternal death audits via verbal autopsies
• Utilization of health facility checklists
• Grievances redressal related to RMNCH+A

61. Monitoring, Information &
Evaluation Systems
• Civil registration system:
Ensure 100% registration of
births and deaths.
• Web enabled Mother and Child Tracking System
(MCTS):
• Link MCTS with AADHAR in order to track subsidies to
eligible women
• Maternal Death Review (MDR):
• Facility and Community based
• Identify causes of maternal deaths and the gaps in service
delivery in order to take corrective action

63. • Perinatal and Child Death Review: Death reports
with cause of death for any child under five should
be shared with district health teams on a quarterly
basis
• Health Management Information System (HMIS)
based monitoring and review: Indicator that reflect
outcomes such as Full ANC, Institutional Delivery,
Sterilization procedure, IUCD insertion, Full
Immunization, Child & Maternal Death which is
regularly monitored and interpreted.
Monitoring, Information &
Evaluation Systems

64. • National & State ‘scorecard’:
• Introduced as a tool to increase transparency
and track progress against indicators related
with intervention coverage.
• Refers to two distinct but related
management tools:
1.HMIS based dashboard monitoring system
2.Survey based child survival score card.
Monitoring, Information &
Evaluation Systems

65. • Review missions:
• Annual Joint Review Missions by the RCH
Division
• Common Review Missions under NRHM
• Concurrent evaluation process led by the IIPS
• Research studies and evaluations done by
international advisory panel
Monitoring, Information &
Evaluation Systems

66. References :
• A Strategic Approach to Reproductive, Maternal, Newborn,
Child and Adolescent Health(RMNCH+A) in India. Ministry of
Health & Family Welfare Government of India February 2013
• Revised operating manual for preparation and monitering of
RCH-II & immunization component of NRHM state programme
implementation plans (PIPs). Ministry of Health & Family
Welfare Government of India. November 2010
• Guidelines for Preparation of Annual Programme
Implementation Plan National Rural Health Mission. 2013-
2014