INTRODUCTION

· Promotion of maternal and child health has been one of the most important objectives of the Family Welfare Programme in India. The current Reproductive and Child Health Programme (RCH) was launched in October 1997. The RCH Programme incorporates the components covered under the Child Survival and Safe Motherhood Programme and includes an additional component relating to reproductive tract infection and sexually transmitted infections. In order to improve maternal health at the community level a cadre of community level skilled birth attendant who will attend to the pregnant women in the community is being considered.

· The need for bringing down maternal mortality rate significantly and improving maternal health in general has been strongly stressed in the National Population Policy 2000. This policy recommends a holistic strategy for bringing about total intersectoral coordination at the grass root level and involving the NGOs, Civil Societies, Panchayati Raj Institutions and Womens Group in bringing down Maternal Mortality Ratio and Infant Mortality Rate.

MATERNAL MORTALITY

· · In the last decades, the life expectancy of the population in India has shown remarkable improvement from 41 at birth in 1961 to the present day of 65 years. Yet, over a 100,000 women in India continue to die of pregnancy related causes every year. The Maternal Mortality Ratio in India is 407 per 100,000 live births (SRS, RGI 1998). The major causes of these deaths have been identified as hemorrhage (both ante and post partum), toxemia (Hypertension during pregnancy), anemia, obstructed labor, puerperal sepsis (infections after delivery) and unsafe abortion.

· · Maternal Mortality is a cause of great concern. However, reliable estimates of maternal mortality are not available. Any intervention to check it will only be effective if we know reasonably accurate data on maternal mortality. An expert group has been constituted in the Department of Family Welfare, which is looking into the modalities of carrying out a survey for collection of data on Maternal Mortality. A Pilot Survey for this has already been completed.

INTERVENTIONS

§ Reduction of maternal mortality is an important goal. The Department of Family Welfare has took several new initiatives, during the current Ninth Plan period, to make the programme broad based and client friendly. The focus was, accordingly, shifted from individualized vertical interventions to a more holistic and integrated life cycle approach giving more focused attention to the reproductive health care. The Maternal Health Programme which is a component of the Reproductive and Child Health Programme aims at reducing maternal mortality to less than 100 by the 2010. The major interventions includes :

§ Essential Obstetric Care

1. Essential obstetric care intends to provide the basic maternity services to all pregnant women. The RCH Programme aims at providing at least 3 antenatal check ups during which weight and blood pressure check, abdominal examination, immunization against tetanus, iron and folic acid prophylaxis as well as anemia management are provided to the pregnant women. Data from the Rapid Household Survey (RHS) 1998-99 indicate that at the national level 67.2 per cent pregnant women received at least one check up but only 10.6 per cent had three ante natal check ups. In Uttar Pradesh and Bihar, the content and quality of antenatal care was poor as compared to Haryana and Tamil Nadu.

2. Keeping in view the already known weakness in programme implementation and in order to improve the delivery of services, all category C districts of 17 States, are being supported for providing additional ANMs in 30% of sub-centre of these districts. In addition, Delhi has been permitted for appointing 140 ANMs for extending services to slum areas. Rs.10988.73 lakhs have been released to the States for appointment of additional ANMs since 1997-98. Public Health/Staff Nurses on contractual basis are also provided to 25% PHCs/CHCs in C category districts and 50% PHCs in B category districts. Under this scheme Rs.3104.73 lakhs have been released to 25 States/UTs.

· Emergency Obstetric Care

1. Complications associated with pregnancies are not always predictable. Therefore, emergency obstetric care is an important intervention to prevent maternal morbidity and mortality. Under the RCH Programme, efforts are being made to strengthen the emergency Obstetric Care Services and make the FRUs operational.

2. Under the RCH Programme FRUs are also being strengthened through supply of drugs in the form of emergency obstetric drug kits and skilled manpower on contractual and hiring basis. The sub-district hospitals, CHCs and FRUs are entitled to hire services of Private Anesthetists for conducting emergency operations for which they are to be paid Rs.1000 per case. Rs.83.73 lakhs have been released to the States; however, Private Anaesthetists have been hired only for 1059 operations so far.

· · 24-Hours Delivery Services at PHCs/CHCs :

To promote institutional deliveries, provision has been made under the current RCH Programme to give additional honorarium to the staff to encourage round the clock delivery services at PHCs and CHCs. This is to ensure that at least one medical officer, nurse, and cleaner is available beyond normal working hours. Under this scheme Rs.1168.88 lakhs have been released to 21 States based on the proposals received from them.

· · Referral Transport :

Time is an important factor for obstetric emergencies. Women who undergo deliveries at home and develop complications often find it difficult to be transported to a referral unit. Under the current RCH Programme Provision has been made to assist women from indigent families in 25% of the sub-centre in selected States to provide a lump sum corpus fund to Panchayat through District Family Welfare Officers. Since 2000-2001, the scheme has been extended to all the States and UTs. Rs.595.65 lakhs have been released 16 States based on the proposals received from them.

· · Safe Abortion Services :

Abortion is a significant medical and social problem worldwide. It is estimated that half the abortions taking place around the world every year are performed outside authorized health services and or by unauthorized often unskilled providers and most take place in the developing world. Whether spontaneous or induced, abortion has been a matter of concern over many decades now, particularly because of sepsis and other complications which lead to maternal morbidity and mortality. In India, abortion is a major cause of maternal death and accounts for 8.9% of maternal mortality every year (RGI 1998).

New initiatives

1 Training of MBBS doctors in Anesthetic Skills for Emergency Obstetric Care at FRUs.

To alleviate shortage of specialist manpower Government of India launched. Training of MBBS doctors for gaining Anaesthetic Skills in Emergency Obstetric Care at FRUs. The 18 weeks training Programme for the first batch has been pilot tested at AIIMS and will soon be disseminated to the States.

2 Obstetric Management Skills

Government of India is also considering introducing training of MBBS doctors in Obstetric Management Skills. Federation of Obstetric and Gynecological Society of India has prepared the training for 16 weeks in all obstetric management skills including Caesarian Section operation and is at present under consideration.

3 Setting up of Blood Storage Centers (BSC) at FRUs

Timely treatment for complications associated with pregnancy is sometimes hampered due to non-availability of Blood Transfusion services at FRUs to facilitate establishment of Blood Storage Centers at such FRUs the Drugs and Cosmetics Act have been amended and guidelines for these Blood Storage Centers (BSCs), have been prepared and disseminated to the States. Initial funding and equipment will be provided by Government of India under RCH-II.

4 Developing a cadre of Community Level Skilled Birth Attendant

· · The major causes of maternal deaths are due to hemorrhage (ante partum and post partum), anemia, infection, unsafe abortion, obstructed labour and hypertensive disorders of pregnancy. A large number of these causes are preventable through improved maternal care and ensuring appropriate treatment of complications, ideally all the deliveries should be conducted by trained health functionaries, however, presently the health care system is not in a position to provide all pregnant women, services of a trained health functionary at the time of delivery. Therefore there is a need for developing a cadre of Community level skilled birth attendant who will attend to the pregnant women in the community.

· · A Community Level Skilled Birth Attendant is a person who will be trained in midwifery to provide maternal care at the community level. She will be selected from the community where she will set up her practice after completion of her training of one year in midwifery. The community level skilled birth attendant will not be a financial or administrative obligation to the health system in any way. They will be left in the villages to practice the skills provided. They will serve in the same community for a minimum period of three years and will not be given government services. They will be given stipend for the training period and hostel facility will be provided at ANM training centres. This scheme will be taken up during Phase II of RCH Programme.

5 Janani Suraksha Yojma

The scheme is a modification of National Maternity Benefit Scheme, referral transport etc. and is at present under consideration.

Objectives

Reduction in MMR & IMR

Focus on Institutional Delivery

Features

Encouraging Small Family Norms

Provision for Caesarean Section

Encouraging Pregnant Women to Undergo Tubectomy/Laparoscopy

Trained TBA to be Effective Link Between Field Level Health Functionary & the BPL Woman

Payment Of Incentive to Dai/ASHA

Fund to be Released Through State SCOVAS/State Department of Family Welfare

Benefit to be Disbursed by ANM through Recoupable imprest

Graded Benefits

Assistance to mother increased to Rs. 700 in rural areas of Low Performing States (>25%) and Rs. 600 to Urban areas of LPS & Rural areas of HPS (<25%).

Assistance package of Rs. 600 in Rural Area for Institutional Delivery in low Performing States to meet Dai/ASHA fee, transport cost and food and incidental charges during delivery.

In Urban Areas of LPS, the assistance package is limited to Rs. 200.

6 Accredited Social Health Activist (ASHA)

Government of India has recently announced a National Rural Health Mission (NRHM) with a clear goal of addressing the health needs of rural population especially vulnerable sections of the society. Such community level link workers may be called as Accredited Social Health Activists (ASHAs). ASHA will act as a link among beneficiary at village level, Anganwadi Worker and ANM. The scheme is under consideration.

Initially it is planned to give this helper (ASHA) to all the villages of EAG States, Assam and J & K. She will help and guide women to assess the health facilities for Anti-natal care, Institutional delivery, post-natal care and counseling on nutrition and Family Planning Services.

7. Vande Matram Scheme:

The scheme is continuing under Public Private Partnership with the involvement of Federation of Obstetric and Gynachological Society of India and Private Clinics. The aim of the scheme is to reduce the maternal mortality and morbidity of the pregnant and expectant mothers by involving and utilizing the vast resources of specialists/trained work force available in the private sector. The scheme intends to provide free antenatal and postnatal check, counseling on nutrition, breastfeeding, spacing of birth etc. through public private partnership.

This is a voluntary scheme wherein any OBG specialist, maternity home, nursing home can volunteer themselves in joining the scheme. Any lady doctor/MBBS doctor providing safe motherhood services can also volunteer to join this scheme. The enrolled Vandematram doctors will display Vandematram logo in their clinic, Iron and Folic Acid Tablets, oral pills, TT injections etc. will be provided by the respective District Medical Officers to the Vandematram doctors/clinics for free distributions to beneficiaries. The cases needing special care and treatment can be referred to the Government Hospitals and institutes, who have been advised to take due care to the patients coming with Vandematram cards. The details of the scheme, reporting format etc. are available with District Medical Officers and Director of Family Welfare in the States.