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&T

Structure

TERNAL AND CHILD HEALTH PRlOGRAMMES

3.0 Objectives

3.2 Child Survival and Safe Motherhood (CSSM) Programme 3.2.1 Organisational Set Up 3.2.2 Programme Strategies
3.3 Reproductive and Child Health Programme 3.3.1 Essential Coinponents of Reproductive and Child Health Progranlme 3.3.2 Elements of Reproductive and Child Health Progrcamme 3.3.3 Strategies 3.3.4 Progralnmc Interventions

3.4 Role of Coinmunity Health Nurse in Reproductive and Child Health Programme
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3.5 National Family Welfare Programme ' 3.5.1 Milestones of Farnily Welfare Programme 3.5.2 Organisational Set Up 3.5.3 Programnc Strategies 3.5-4 Role of Nurse

3.6 Some Important Points to Reinenlber


3.7 Let Us Sum Up

3.8 Answers to Check Your Progress

3.0 OlsJECTIVES
After completing this unit, you should be able to: hescribe the various types of health services available for mother and children; explain various activities for maternal and child health; discuss the various activities under national family welfare programme; enumerate the functions of a multipurpose fernale health worker at sub-centre level; explain the national status of vaccine preventable diseases; and counsel a couple for adoption of a family planning meel~od.
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3.1 INTRODUCTION
A number of national programmes have been launched by Government: of India at various periods for the developmerlt of women and cltildren in India, These programmes have undergone many modifications i'rom time to time and, presently, they are being implemented in the form of two health programmes i,e, National Family Welfare Programme and Reproductive and Child Health Progrmme. The Integrated Child Development Services Scheme the Rural Water Supply and Sanitation Programme are being implemented by different ministries but have a direct impact on the development of child and mother. These two are being dealt separately in this Block,

In this unit, concepts,of Reproductive and Child Health (RCH), Child Survivd and Safe Motherhood (CSSM), and Family Welfare (FW) programmes are discussed in

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Role of Nurse in National Hea3th Programmes

brief. During your visit to the Primary Health Centre, you should try to accluaint yourself with the functioning of comF~onents. YOU should also discuss each OF them with your counsellors. Your understarldirlg of this unit is very important, because, the Public Health Nurse is the key perscrll in shaping the aspirations of mother and child in health sector.

Care of mother and child occupies a lparhount place in our health service delivery system. This is reflected from the facr that the goals listed in National Health Policy (1983 and 2002) focus on maternal and child health. .
In addition to modifying the National Family Planning Programme to National Family Welfare Programmes, few more health activities were in~plemented for promoting the maternal and child health under various progra~~~mes, They are Universal Immunization Programme (UIP),'Oral Rehydration Therapy (OItT) Progranme, Prophylaxis Schemes against nutritional anaemia among pregnant women and scheme against blindness due to Vilalnin A deficiency nrnong children under 3 years of age. Implementation of U P as a national nussion provided long desired access of immunization to children. Hence, as a next step, package of comprehensive health care to children and mother was perceived to be feasible and the health package was implemented in the f o m of a project which was extended as Child Survival and Safe Motherhood (CSSM) Programme since August, 1992. This package included d l the previous programmes meant for mother and child and added few more coinponents like Acute Respiratory Iilfection (ARI), First Referral Units (FRUs), Delivery Kits to pregnant ladies etc. The goals to be achieved by 2000 AD under CSSM prograrnrnc were as follows:

Under the CSSM progratnme, child survival component had been implemented in all the districts of the country but the safe motherhood programme was i~nplemented only in the states having high IMR and MMR i.e. Bihar, M.P., Assam, Orissa, Rajasthat1 and U.P. (in shlort. called BMAORU states). The National Population Policy (2000) Indicators for MCI-I are given in Table 3.1 below:

Maternal and child Hcalth Programmes

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As mentioned earlier, the health delivery access was already available from UIP, Hence, the infrastructure of p r i ~ w y health care delivery system (i.e. Sub Centre PHC CHC Dist. Hospital State Centre) is beirlg used for this programme dso. The only additional component is the establishment of 4 to 6 First Referral Units (l%U.Js) at the sub district level of every identified district for improving the emergency obstetric care. All the 219 districts in h e state of Bihar, Madhya Pradesh, Assam, Rajasthzln, Orissa and 1J.P. are included, These FRUs were planned to be equipped with one specialist each in Qbsteulc and Gynae, Paediatrics and Anaesthesia with f a l i t y of operation theatre, blood transfusion and laboratory facility. One staff nurse will also be there to tnke care: of ildmilted patients.

Rote of Nurse in National


Health Programmes

The concept of Baby Friendly Hospital was also included in CSSM Programme to promote the breastfeeding in all the hospitals having the-dqlivery facility. These hospitals will promote the baby friendly practices i.e., provision of antenatal care, essential newborn care and iinmunization in addition to appropriate management of ARI and Diarrhoea. All the staff of these hospitals must be aware of advantages of breastfeeding and the hospitals should lceep the mother and babies together for all the 24 hours a day and initiate breastfeeding within 1 hour (ofnormal delively or 4 hours of Caeserian Section. No artificial pacifierlteat shoul~d be allowed. Provision must be created for on demand breastfeeding facility.

3 . 2 . 2 Programme Strategies
As mentioned earlier, the CSSM programme is a combination of programmes. Each component is being dealt separately. 1) Child Health Universal Zmmunization Programme (UP)
The UR?was launched in 1985 hnd was declared as one of the technology m~ssions in 1986. Initially, the target was to achieve the immunization coverage of 85 per cent in BCG, DPT, OPV and measles but under the CSSM this target was changed to 100 per cent coverage of infants. 100 per cent coverage target was also kept for tetanus toxiod to pregnant women.

The vaccine coverage as found in 1996 was as follows:


BCG

DPT

98%
93%

OPV
Measles

93%
89% 84%

T.T.

India is self sufficient in production of all vaccines except BCG and OPV. The capacity of BCG producticm is likely to be met in near future. 91% of OPV samples in the field testing has shown that cold chain is being mainrained satisft~clorily.

National Immunization Programme


The National Immunization Programme is one of the largksl and the most successful national p r o g r a m s . The success of the programme ccan be rncnsured directly in terms of reduction of childhbod morbidity and mortality associated with diphtheria,pertussis, poliomyelitis,measles, childhood mberculosis and tetanus. In . less than two decades since the programme was started, goals have been set for the eradication of poliomyelitis and virtual elimination of neonatal tetanus and measles. This has been possible because of significant reduction in the incidence of diseases. As a result of the programme, more than three million young lives have been saved. The National linmunization Programme was started in 1978 as the Exl~ai~decl Programme on Immunizatio~i (EPI) with the objective of increasing immunization coverage in children under two years of age with three doses of DPT and one dose of BCG vaccine and in pregnant women with two doses or a booster dose of tetanus toxoid (TT). Oral polio vaccine was added to the Programme in 1979. Coverage levels increased to about one-third of the estimated levels in children . under two years and pregnant women.
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In 1985, the objective of National Immunization Programme was revised and renamed as'universal Immunization Programme for attaining universal immunization coverage of infants and pregnant woAeR. Measles vaccine was added to the Programme in 1985. This Programme was taken up as o11c of the five technology missions of the Prime Minister in 1986. Adequate funding was provided

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by the Government of India for the establishment of a reliable cold chain system and a logistic network was developed for ensuring regular and smooth supply and monitoring of services. Training oJ' medical and para-medical personnel was undertaken to assure high quality of services. Besides the goal of developing a reliable cold chain system for the storage and transportation of vaccine, a major goal was to attain indigenous self-sufficiency in the production and quality control of vaccines. Due to the enormity of the task, UIP was taken up district-wise in phases over a five year period from 1985-86 to 1989-90. District-wise monitoring was introduced.

Mnternnl and C'hild Health Programmes

Expanding Coverage Levels


Prior to the 1980s immunization cfsveragelevels were negligible and the vaccine preventable diseases (VPDs) were widespread. These constituted a major proportion of the total childhood disease burden in the country. Sampel surveys conducted in 1981-82 confirmed lahatnearly 0.3 million newborns died annually due to tetanus and that more than 0.15 nnillion children developed paralytic poliomyelitis every year. The neonatal tetanus mortality rate was 13.311000 live births in the rural areas and 3.211000 in the urban areas in 1981. The incidence ra1.e of paralytic poliomyelitis was estimated to be 1.S to 1.711000 children 0 to 4. years of age (around 711000) live births prior to thie polio immunization progriimme. Currently, nearly 80% of the 27 million pregnant women and over 85% of the 25 million infanls are receiving the lull course of the vaccines annually. Immunization coverage levels have more than doubh~d since 1985-86. Dropout rates have reduced and children are being increasi ngly brought to Lhe ilrlmunization sessions at the right age. Awareness about the iin~~unization programrne and demand for the services are high, Icnrnunization of worncn with two doses or a booster dose of (TT) in pregnancy has similarly shown is steady increase.

Vaccine Logistics
The vaccine recluirenlenls in India exceed that of any other country. Together,. annually. In 1992-93, for example, nearly half a billion doses of vaccines are ~lscd 100 million doses of OPV, 123 inillion dosc s of DPT, 133 million doses of TT vaccine and 35 to 60 million doses each of BCG, measles and DT vaccines were procured for the Programme. The require1nc:nt of OPV has trehlcd since 1995 after the start of thc pulse polio immunization for t~he eradication of poliomyelitis. India is self-sufficient in the production of all vaccines, except for OPV. Part,rt:quirccnents of BCG are imported. OPV is blended locally from imported bulk conaentrates, The maintenance of a regular vaccine flow to all conlers of the country is a mcljor challenge. Not only must the vaccines be kepi under a strict temperature: range, coml~ared to other drug:?. The these also have a relatively short shelf-life wh1e11 programme further aims to keep vaccines for as short a period as possible at the peripherdl institutions (not more than one lnon th's requiren~ent plus buffer at the PHC), as a further safeguard. Safe regional and district vaccine stores h~awe been of vaccine supplies. Information on established to ensure that there is no disruptiot~ vaccine movement and utilization is critical in I naintaining a smooth flow lof vaccines. Vaccine logistics, therefore, Forms a x iimportant conlponent of 1 1 1 e immunization cormnunicn~on network. Besides the obvious progress in imlnunization {werageand reduction In disease incidence, there were other significant positive fallout of the Progarmme. First of' all, high levels of contacts have been establishel3 with the community, particu1arI;y pregnant women and women with young children. The demand for the servic& ,is high and has led to the improved status of the p~e!ripheral health staff. The logisticis network established to operationalize a prograrrme of the magnitude of the Immunization Programme, which provides regu~lar services on fixed days and sites to around 12.5 millibn p r e g m t women an'd infgmts monthly, has given the health system confidence and credibility.

Role o f Nurse in National Health Prograrn.rnes

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While the overall achievements under the prograimie are impressive, a large number of children are still denied the benefits of iu~lmunization. In some areas immunization coverage levels are dropping underscc:~ring the need for constant monitoring and sl~pervision. While the achievement:; to date are significant, colnplacency ancl a false sense of security can be dirsastrous. High levels of immunization cowerage levels of quality of services must be sustained at all costs.

New Initiatives for Vaccine Preventable Disease s


World Health Asisembly declared in May 1988 to e~iadicate Polioinyelitis from world for at least 85% colte,rage of OPV, have mop up by 2000 AD. It ~reco~mended round in high risk pockets, have special iimuniza'ionl sessions and do surveillance of Acute Flaccid Paralysis (h). The objective ,was to achieve nil incidence 0'1 poliomyelitis by 1,977 but it is continued and it may soon be declared as polio free.

In mop up round, children up to 3 years are covered and giver1 2 doses of OPV b irrespective of the imlunization status of the child. 'tn India, Pulse ~ o l i Ca~npaign started in Delhi in 1994:-95 and was carried out at n ational level in DecemberJanuary months of 1995-96. The objective is to rep'lace the wild polio virus by the vaccine virus. Delhi anal few states have started re ;porting of zero incidence of poliomyelitis. Intensive plulse polio campaign is be dng obse~ved to achieve polio free India.
To achieve the success of eradication, scope for on demand free supply of OPV to professional organisations, voluntary organisatio n and private practitioners is made by the Government of dndial. AFP surveillance i f ;being made since 1992.

ii) Elimination

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Neonatal Tetanus

The goal was set to eliininate neonatal tet ,anus by the end of 1995. The steps that are being followr :d as a p a t of the stratel gy are:

0 C J% coverage of all pregn ant women by tetanus toxoid, To have 1


Conduction of all deliveries by trainf:d dai,

Supply of cl .elive~y kit lo pregnant wor nen, Provision crf essential newborn crue tc ) all newborn children, and The survr jil ilance

2) Essenti:nl Newborn Care


Essential ne .wb orn care aims at providing r xarmth, nutrition and control of infection of the newt >om . Mucous suction trap is be dng supplied to ANM. Warmtll could be achieved ,y us ing table lamps. The mothe :rs are being encouraged for exclusive breastfeet'ling p lractices. Clean delivery p$ actices including cord care, handwashing are being<enforced for infection control.

The cas e of neatiatal tetanus is suspect ccl when a child of less than 28 days remain! s normal for at least 2 days afte ,r dlelivery and then becomes unable to suck with ej >isodes of convulsion and stiffn ,ess . In the districts, where neonatal tetanus is one pel. 1000 live births, all the I ieonatal deaths should be reposted, less tb,~a11
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Neonatal tetanus can be claime4as eJi~ninatedif: The incidence is less than one per 10: 000 live births, More that 90% pregnant women are protected bly tetanus toxoid, ;and More than 75% deliveries are cdnducted by trained personnel.

Maternal and Child Health Programmes

Prevention of Measles
The goal of CSSM programme was L o prevent 90% of occuirrence of measles and 95% of deaths due to it by 1995. The: strategy being followed was to have a high immunizalion coverage, identification of high risk poclicets for measles and treatment of complicittions due to measles.
A single case-of measles was co~lsidleredas an outbredc. The cllistrict authoi-ily was instructed to step up the irnmunizal~ic~n and Vitamin A coverage clui-ing an outbreak

of measles.
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Orul Rehydratioiz l'lterapy fi)r IDiarrlzoen Control ainorzg Chi'ldrcn


:rhe OKT programme started in I 985 and was launched at national level in 1986. It L-~ecarne n par1 of CSSM prograrrimc in 1992. The goal wiis to decl-ease the ctiat~hoeal death in under five chiildrc:n by 70% by 2000 AD.

The strategy Sollowed was L o pru1,notc breastfeecling, make provision for su,pply of ORS, encourage home management of dimhoeu and have a stmd:lrd case management approach by c1inici.i.m~ (Also refer Appendix 2). Accordingly, the mothers will b e given QRS packets even if the child with di,mhoea does not have signs of dchydrat.ion in CSSM distsicts, OIiS packets were being supplied as a part of' sub-centtr: Itit. Diarrhoea Treatment Units (DlTUs) were being opened under pacdialric depart men1 of medical colleges.

Preveiztion ant1 Coiztrol qf Vi;ltnrninA deJ4ciency nrnoizg Cl&ildr,en


This component is being dcscr ibed in unit 4 of this block under National Progriim~ne for control of blindness. Unclelr the CSSM programme, six doses 01' c0ncentrate:d Vitamin A were to bc given to all children between 1 to 3 years at 6 ll~onthly interval. The 1st dose is linked cluring ~neaslcs vaccinr~tion at 9 ~llalnths to 12 months and the 2nd dose is linked with booster dose of DPT/OPV. Pron~o ti011 of is one ad' the strategy for prc:vcntion of breastfeeding specially the colos;tru~n Vitamin A deficiency in infants.

Acute Respiratory Infection (I! rzeumonia) Cc1ntr.01


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Plleunlonia contributes to 20% o f under-five deaths in India. Her lce, a stra~l.., developed in 1989 and was imple mented in 24 districts in 1991 which showed that the trained hcalth workers are abi le to correctly diagnose and treat pneumonia.
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Accordingly, cotriinoxazole tablet .s were being supplied lo healtl~ ,workers througlz CSSM drug kit. The diagnosis of pneulnonia was rllude by countiing the respiratory rate as per the guideline (Also rc fer Appendix 2). The severe czises are refen-ed and the rest are given cotrinlaxe xole tablets tvvice a day for 5 days. Now Integrated Management of Neonatal and C h:ildhoocl Illnews (IMNCI) appro<icl~ is followed to assess, classify and treat sickne ss in Newborn and Children. Under this approach common illness anlong newborr I and children irs managed which i include pneumonia, diarrhoea, dysentry, fever, lnala ria, measles, anaemia, rnalnutritic m and immunization.
3) Essential Maternal Cal re

It includes early regisfxation r ,f pregnancy, three antenatal check ups, universal provision of IFA tablets and 'dnjection T.T,, ear1;y detection and r c :fe$al of maternal complications, management of obstetric emnerge,ncy,instilutional delivery of high risk motl~ers, advice of food and rest in pregnancy iind birth spacing.
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Role of Nurse in Nationral Health Programmes

The Birth Attendants were trained in leach village so as to have at least one Trained $ Birth Attendant (TBA) per village. The TEA training started in 1974. But under the CSSM programme, all the dais were undergoing a 6 days residential training in a rural institution where at least 50 deliveries take place per month. This was canled out by LHVPHN under the guidance of the Medical Officer-In-Charge of the institution who in turn reports to the district immunization officer. The administrative link for the TBA training was as below:

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MOIIC of~raihing Institution

Fig. 3.1: Administrative link for TBA training

Each ldai was given Rs. 40 per diem for the training pr:riod in addition to the travelling allowanlce. Five to six dais were trained peir session and each dai had to condrrct 3 to 5 deliveries during training, Tlpy were being trained in five clean . practices, They are: Clean surface for delivery Clean .hands o f the attendant

Wew blade of cutting cord Clean tie for the cord

No applicant c 3 n the cord stump.

At the end they were given'a kit. Under the programe, the dai will get Rs. 10 for rAaeporting of each delivery she conducts in her area. 'The disposable kits are being provided to all pregnant wonien. It was aimed at enlruring access to dl pregnant women by TBA by the end of 1986. Now the concept of Accredited Social Health Activist (ASHA) is promoted under National Rural Health Mission (NRNM) to mother and children. (See App lendix 1). cater to the needs o~f Anaemia Prevention and Control among Pregnalvt Women
Anaemia accounts For 20 per cent of maternal deaths. While less than 12 gm% of Haemoglobin in nola pregnant women is regarded as .anakrnia, the; norm for pregnant ladies is klpptat less than 11 gm%. As you know, hookworm infestation is a major cause of anaemia. Hence, provision of 6 tabltrt of rnebendazole (100 mg BD x 3 days) is marde for pregnant ladies. The other strategies include promotion of iron rich diet, spacing of birth and supplementation of ilFA (Iron and Folic Acid) tablets for 100 days starting after the 1st trimester of plregnancy, In addition to 60 - mg tablets, IFA tabhkts having 100 mg Iron and 500 mg ~ b l i acid c is made available under CSSM Progrrunme. For Pregnant .and,lactatingw~omen,1 tablet is given thrice a day for 100 days.

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For children, the IFA tablet is available in the form of tablets having 20 nng Iron and 100 mg folic acid. The reconmendation is to provide one such tablet per day for ' 100 days each year. As Vitamin C increases absorption of Iron, consumption of citrus fruits is encouraged. Mothers are advised not to take tea within a few hours of taking the F A tablets as it decreases the iron absorption.

Mnternal end Child Health Programmes

3.3 REPRODUCTIVEAND CHILD HEALTH PROGRAMWIlE


During international conference of population and development which .was held at Cairo in b994. India was the signatory to the recommendation made and these were: Reproductive health care should be made available through primary health care system maternal mortality by 50% Need assessinent and need fulfilment as the key elements of improving reproductive health.

- Effo~ts should be made by all states to reduce infant morlality by one-third and

According to WHO reproductive health implies that people are able to have a responsible, satisfying and safe sex life and that they have the capability to reproduce and the freedom to decide if when and how ol'ten lo do so. This focuses on right of men and women to be well informed of and to have safe, effective, affordable, acceptable methods of fertility regulaiion of their choice and the right of access to appropriate health care services thal will enable women to go safely through pregnancy and childbirth and provide couples with chance of healthy baby. The programme covers all the components of CSSM Programme (Section 3.2) and in addition a few conlponents have been added as discussed below (See Appendix- 3 for details).

3.3.1 Essential Compdnents of Reproductive and Child Health Programme

Prevention and management of unwanted pregnancy Maternal care that includes antenatal, delivery and postparlum care

- Child survival services for newborn and infant - Management of reproductive tract infection and sexually transmitted diseases. 3.3.2 Elements of Reproductive and Child Health Programme
a) Reproductive Health - Responsible healthy sexual behaviour - Intervention lo .promote safe motherhood

- Prevention of hnwanted pregnancies


Safe abortion Management of RTI and STD Reproductive health services for adolescent

- Pregnan~y and delivery services

Screening and treatment of infertility, cancer and other gynaecological . disorders. b) Child Survival Elements - Esientid newborn - Prevention and management of vaccine preventable disease

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Role o f Nurse in National Health Programmes

Urban measles campaign

Neonatal tetanus elimination Cold chain Polio eradication ARI control programme Diarrhoea control programme P~evention and control of vitamin A deficiency I3 aby friendly hospital initiative,, Integrated management of neonatal and childhood illness.

3.3.3 Strategies
Community need assessment (target free approach). Target free approach was accepted in 1996 for implementing family welfare programme. To make this programme a people's programme, target free approach was renamed as community need assessment approach. This focuses on: - Decentralised participatory planning and implementation - Strengthening infrastructure

Integrated training package Improved management and inanagement information system. Safe mo~erhood interventions - antenatal check up, immunization for tetanus, safe delivery and anaemia prevention Child survival interventions- irnrnunizati~n, vitamin A prophylaxis, oral rehydration and prevention of AN Operationalization of community assessment approach High quility training of health personnel at all levels Strengthened management information system Counselling on health, sexuality and gender Specially designed RCH package for urban slums and rural areas RTI and ST1 clinics Facility for safe abortion Enhanced comnkmity participation through Panchayat, women groups and NGO's Provision of lab facilities for diagnosis of RTI and ST1 Adolescent health and reproductive hygiene 1nvolvement.of Indian system of medicine.

3.3.4 Programme Interventions

3.4 ROLE OF COMMUNITY WEALTH NURSE IN RCH


Maternal services include care and guidance of nlother during pregnancy, delivej" and post natal period. The health of the child and the well being of the mother depend upon health and the welfase of the family to which they belong. Conditions like poor housing, poor environmental sanitation, shortage of food, ignorance and supet-stition,have adverse effects on children and adults. The nurse functions as a member of the maternity team, which includes doctor, nurse, health assistant, midwife and dai. As a PHN you have to supervise the activities of the MPW (F) at subcentre. The expected works at subcentre level is shown in the table form.

Maternal and Child Health Program~t~es

IFA-Large, Safe delivery, Referral for women at risk and those

The services il~dicated in this column is only a ptutii~l list of services, discctly sclalecl to the CSSM progranmc.

The main functions which a nurrsc may perform within the team are given bclow. You refer to Appendix 4 for the expected list of activities by MPW (F) in the Cield,

Maternity Health Services


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Contact wilh every expectant mothcr early in pregnancy to help her to secure medical and social services during pregnancy,
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Help mother to plan for safe delivery ancl for safe postnatal care, Teach essentials of safe maternity care to mother and attendants, Supervise the care given, whenever possible, Train midwives and dais and participate in training programme for nurses, Manage maternal m d child welfare clinics, Liaison work with maternity hospital, centre, Conduct mother craft and chid care classes for parents and other !pups, Help the mother during her confinement at home and in centre setup, clnd Help to maintain continuity of services from conception to postnatal period,

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RoIe of Nurse in National Health Progranlmes

Providing child health services is to ensure:

Every child grows up in healthy surroundings, received proper no~~rishrnent and. adequate .protection from diseases, Control of communicable disease and adequate preventive measures immunization of diseases, and heaIth education, Early detection of diseases, Education for mothers in the care of healthy as well as sick children.

During home visit, you should identify high risk children and give priority care to those children. High health risk children ase those:

Who are low birth weight babies, For whoin breast feeding is not established, Whose birth order is more than five, Who show no weight &in,
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Whose mother is dead.

3.5

NATIONALlFAMILU WELFARE PROGRAMME

India launched the National Family Planning Programme in 1952. It was the 1st nation in the world to launch a nation-wide programme till 1997 and different Components of family planning services were added and the infrastructures were strengthened.
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Medical Termination of Pregnancy (MTP) was added in 1972 and the national populatioa policy was framed in 1976.

In 1977, the programme was renarned as Family Health Programme and a number of welfare components were linked up. More arid more emphasis was given for female literacy, poverty alleviation, improvement of nutritional status and I.E.C.
The long tern objective of the family welfare programme in India is to stabilize the population at the level of some 130million by the year 2050 AD through small family norm. This would be possible if the mid-tern objective of achieving Nct Reproductive Rate (NRR) as unity is achieved. The present estimate was set to be' achieved by 2000 AD and is now set to be achieved by 2016 AD. I
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3.5.1 Milestones of' Family Welfare Programme


1951-58
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Maternal and Child Health Progra~nmes

- Family planning programme adopted by


Governmei~t of lndia, first of it's kind in world.
- Extension education approach. Department of Family Welfare under Minishy of Health. Target oriented approach. Lippies loop introduced.

- Family planniilg services under primary


health centres. All India hospital post pastum prugrrunme. Medical Termination Act. (I 97 I),

Renaming-l'amilyplanning to family welfidre. Conlmunity involvement, Child Marriage Act

- National I-Iealth Policy.

St.sengthening Maternal child and fanlily welfare. Inclusion of various programmes under MCH pragranlme. Child survival and safe rnmllerhood programme:
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Interni~tional conference on population and development (Cario - 1994). Target free approach. Review of CSSM Prpgrtunmc Reprocitxctive Child Health Programme (RCI-11) wit11 KT1 and ST1 coinponents. RCM 1 1 . National Rural Health Mission.
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3.5.3 Organisational Set Up

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The DeparUnent of Family Welfase is responsible for the implementation or thc National Family Welfare Programme. It was; formed in April, 1966 and headed by a Secretasy to Government of India. The Cenwal Cotincil of Hcalth and Family Welfare reviews the implerncntation of the prcgramme, The Council is headed by the Union Minister of Health and Fanlily Welfare having all the Health Ministers of various states as members, along with othcr members of xndjor voluntary organisations,Planning Commission, ctc. . There are seven regional health and ftmily planning offices in Ahemdabad, Bangalore, Bhopal, Calcutta, Patna, Chandigarh and Lucknow, each headed by a Regional Director. The Regional Offices act as n liaison between the centre imd state governments. Each state has a Family Planning ~ u r e i u being hcaded by thc StatesFi~mily Planning Officer. In somk states, the bureau Inas a separate Director and in other states it continues to be under the Director of Hedtli Services,
At the district level, District Faxlily Welfm Bureau is responsible for the
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Role of Nurse in National Health Programmes

implementation of programme. The Dislrict Collector coordinates the family welfare activities of the district with other departments. There are 5435 Rural Family Welfare Centres existing at Block level. Till 1980, Rural Family Welfare Centres were implementing the national programmes. But now the health and family welfare is being implemented in an integrated way. Hence, new Rural Family Welfare Centres are not being created. The schematic structure of the National Family Welfare Programme is as below:

(Health & Family Welfare Department)

( City Family Welfare Bureau

Welfare Centre

ry Health Centre (

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Pig. 3.2: Schematic structure of National Welhrc Programme

In the urban areas, the city Family Welfare Bureau is responsible for the iinplementation of the programme. The structure of the City Farnily Welhre Bureau depends upon the population it serves. 5 p e I (2-5 lakh) has one Medical Officer, Type II(5-7.5 lakh) has one Extension Educator in addition to the Medical Officer, Type 111 (7.5-10lakh) has one Medical Officer and two Extension Educalors (M & F), and Type IV (above 10 law) has the structure similar to District Fa~nil y Welfare Bureau i.e. One Family Planning Officer, 011e Mobile Sterilization Unit (having an Asst: Surgeon, 0.T. Nurse, 0.T Attendant),

One NCD Mobile Unit (one Asst. Surgeon, one AIYM),


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A Separate Education and Information Division, and


One Field Operation and Evaluation Division.
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Initially, various types of urban family welfare centres i,e. Type I, I1 & JlT were / established to meet the need of population of 10,000 to 25,000 to 50, 000 and more' than 50, 000 respectively. There were 1499 such centres as on 1994, These centres1 are being converted to health posts in a phased manner as discussed below. I

As per the Krishnan Menon Committee recommendations, the urban revamling j scheme was launched. Accordingly, 4 types of health posts were created (A, B, C, D) to cater to the: need of less than 5000,5000-10,000, 10,000~25,000.and
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25,000-50,000 population, respectively. The detail's of these health posts are shown in the schematic presentation below:

a1 and Child

IS

Programmes

1 City Family Welfare Bureau (Type I, 11, ill, IV) I


7

r
Urban Family Welfare Bureau

!
(4000) ANN-I
(5000 t o so, 000) Volunteer-1 Per 2000 Popu[ation

(10,000 to 15,000)
MPW-2 Volunteer-1 per 2000.

ANM-1 MPW-1

per 2000'

3.5.4 Programme Strategies '

Fig. 3.3: Schematic presentation of health posts ..


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The family welfare prograrhme as being implemented now has evolved dver last 4 decades. Seventeen goals were fixed in the National Health Policy (1983) to be achieved by 2000 AD. The important goals related to this prograrmrie were: Net Reproduction Rate (NRR) - 1, i.e., one female: one female child, This is -. possible with two child norm,
a

Family size 2.3, Effective Couple Protection Rate (ECPR) 60%, Crude Birth Rate (CBR) 21, and Crude Death Rate 9.

The 79th amendment Bill, 1992 aimed at 2 children norm as fundamental duty. Similarly, the prenatal diagnostic technique Act, 1994 limits the prenatal diagnosis to be made in registered institutiotis and in certain circumstances only the routine activities under the programme,

Conventional Contraceptive Programme # Conventional Contraceptivesare provided through free distribution system in all the health institutions. The village Health Guide acts as a depot holder of Nirodh, It is available in packets of six. Under commercial marketing scheme various good quality Nirodhs are made available in open market. It is also being made available through Public Distribution System (PDS) in 12 states. ii) Oral Pill Programme
Oral pills are being distributed free of cost in the brand name of 'Mala-N', it is distributed by ANM, L).N, PHN and Medical Officer. As you know the oral contraceptives have side effects and certain conuaindications. Hence, the acceptors should be examined by a doctor in 3 months time if not examined earlier (Also refer Appendix 4). Social marketing of oral pill was introduced in 1987 and, presently, available under various brand names. 'Mala-D and Mala-N' is available.

i)

Role of Nurse in National Health Programnles

A norlsteroidal preparation under the name 'Saheli' is aiso available as a weekly oral pill in the open market.
iii) 1.U.D

The facility for Cu.T insertion is available at P.H.C and higher set ups. It is also being made available at Sub-centre level. Previously, a compensation of Rs. 91was being given to acceptors. But it is stopped since November, 1993. Presently, government provides Rs. 31- to the institution towards the cost of medicines and complications arising out of the procedure. iv) Sterilisation Facility for permanent ligation (vasectomyltubectomy)is available at Primary Health Centre and higher set ups (Also refer Appendix 2). Under the . sterlisation bed scheme, sterilisation beds are made available even in nongovernment hospitals and government provides Rs. 300Ofbedlyear if more than 60 Bigationshed take place in a year and Rs. 2400lbed.lyear if 45 sterilisation/ bed takes place. The minilap tubectomy is practised by medical officers in P.H.C and famiIy planning camps. The laparoscopic ligation is done by the gynaecologists at postpartum centres and institutions. A two week training is being provided to doctors for this purpose. No scalpel vasectomy has recently been introduced to increase the male acceptors for permanent ligation. Recanalization facility is also being made available for desirous people. Training of doctors in recanalization procedure is being done at Delhi, Bombay, Calcutta and Madras. Government of India has a provision of Rs. 1801- per vasectomy case and Rs. 2001- per tubectorny case. This money is being provided to the institutions for the operative cost and compensation to the acceptors. Rs. 2001- for conventional, Rs. 145/- for laproscopic method of tubectomy. Rs. 101- is given to tubectomy motivator and Rs. 40;- vasectomy motivator. Other incentives are:
I

2 increments after two children, one increment after 3 child norm after . three children norm by the State Government and one increment by the Central Government. Special leave.

Female - 14 days. Male - 7 days. No maternity leave after three children.

v) All India Post Partum Programme


It is hospital based maternity centre approach started in 1969. The objective is to promote health of mother and child. Und~r this programme, post partum centres are attached to 100 medical colleges, 550 district level and 1012 sub district level hospitals. The objective is to provide antenatal, natal and postnatal services to expectant m o ~ e r including s the family planning services. i A scheme of PAP smear test is functioriing in 80 medical colleges of the country. It aims at detecting cervical cancer among women acceptors of contraceptives.

vi) Expanded Programme of Medical Termination of ~ r i i n a n c ~


Under this scheme, MTP Cell is being created in a l l states where an average of 10,000 MTP are done in 3 years. The doctors are being trained in MTP techniques and other surgical procedures including spacing methods. Facility of suction aspirators are being provided to PHCICHC where these trained doctors are available.

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vii) Social Safety Net Scheme


Under this scheme, 90 weak districts are identified in the whole country where
.crude birth rate is more than 39 per thousand. Five Primary Health Centres

MaternaT and Child Health Programmes

(PHCs) in each of these districts are identified for upgradation. Each of these PHCs will be provided facility of one operation theatre, 6 bedded observation ward, labour room, one generator for continuous electricity supply, one ambulance, one water pump for water supply to PHC and two quarters for ANM and LI-IV. Out of lhese 90 districts, 83 belong to Bihar, M.P., Rajasthan and U.P. whereas the rest are in Orissa, Haryana, Kerala, West Bengal and Gujarat.

viii) Mahila Swasthya Sangh (MSS)


This is an association at sub-centre level to create the IEC network for family welfare service. It was started on pilot basis in 1990-91. As on 1993, a total of 4,772 MSS has been established. The MPW (F) is the convenor who organises the monthly meeting of MSS and discusses on topical problems related to MCH (i.e. ARI, safe delivery, contraception, immunization, etc.). Besides the MPW (F) it involves the village level woman fui~ctionaries i.e. A n g a n ~ a d i ~ worker, lady teacher of the school, adult education instructor and 10 active women from different communities. Government provides a grant of Rs. 1200/ year for the activities of MSS.

ix) Gram Pariwar Kalyan Samiti


This is a village level committee for pron~otionof fariily welfare activities. The 'Sarpanch' of the 'Gram Panclzayat' is the Chairman and has the following people as members. They are MPW (F), Anganwadi worker, village teacher, 'Patwmi' and the village members to the Gram Ywchayat. The main function of this coinmiltee is to pro~nofe family planning metfiods and implement the Child Marriage Act in the village in addition to promotion of MCH services.
X)

Mini Fanlily Welfare Cetnre Scheme (Revamped)

- Revised

To increase the acceptance of fatnily planning in the districts having couple protection ;ate less than 35%, Govt. has introduced this scheme. 144 dislricts covering 10 states i.e. Andhra Pradesh, Assarn, Bihar, Himachal Pradesh, J & K, Ka-natraka, M.P., Rajasthan, U.P. and West Bengal are identified. Under this scheme a project will cover minilnuin 25,000 population. Each project will have one Project Coordinator and 25 sahelies, Each Saheli wilI cover 1000 population and one out of each 5 Saheli will acts as a supervisor, An NGO will be given assistance of'5 lakhs/year for such a Project coverning 25,000 population in rural area and 6.6 lakllfyear in urban area. The target for them would be to cover 100% eligible couples with either a permanent method or a spacing method. The project coordinator and the Sahelies wi1,I have to undergo a 6 days training at HFWTCs or identified government institutions. A profesbsional nurseldoctor may be appointed as a Project.Coordinator. The sal~eli should be literate lady who could be selected from Anganwadi Workers, Balwadi or Teachers etc. A six monthly progress report is required to be submitted by the project coordinator LO the Government of India,

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Role of Nurse in National Health Programmes

3.5.5 Role of Nurse


Many opportunities are available to community health nurses to be involved directly or indirectly in the family welfare services. In all areas of her work, her actions are direcled towards:

Identifying eligible couples who desire to have children and those who do not want to have them, motivating, giving Providing and interpreting family planning infor~nation, services and tapping community de\lelopments for resources, Helping in planning, implementing and evaluating family welfare services and organising family welfare camps,

Follow up of those who have adopted devices or are operated,


Initiating and contsibuting towards research, and

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Participating in planning, conducting, evaluating training programme for other paramedical staff.

In clinical set up, the PHN has following roles:

Organise clinics, Supply and equipment, Supervise slerilisation of equipment,

Display of educational materials, aids, Counselling and guidance, Assist Medical Officer in conducting clinics, Plan, conduct, supervise and evaluate health education programme, Referral scllrices to hospital, and Supervise the maintenance of pertinent registers and records for eligible
' couples, lists of acceptors of both temporary and peilnanent methods, follow-

up and record of vital events.

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During Home Visit


Comnunity health nurse is to prepare work plan to include home visit to supervise field staff and help thkm to:
I

Classify couples into high, medium and low parity groups,


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Matcrnal and Child Health Programmes

Review list of couples using, not using and never have used family planning, and planning their future plan of action, Supervise, effective folllow-up of users with regard to side effects, related complications and failure, Keep motivating and encouraging users,
,

Identify women requiring help lilte MTP or any other and to refer them to suitable agencies, and Maintenance of registers.

The success of family welfare services mainly depends upon how well informed are the individuals and couples. Therefore, the community health nurse must utilize and explore various means of giving education through mass media, radio, I.B. programmes. She should coordinate with district mass education and ~nformation Officer and Extension Education Officer in order to strengthen information, education and communication components.

3.6 SOME MPORTANT POINTS TO mMEMBER

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All pregnant women should have 3 ANC's, 2 TT's and at-least- 100 IFA tablets during pregnancy. All deliveries should be conducted by trained dai's or health worker in a clinic and in hygienic environment. Danger signs of pregnancy like bleeding, headache, dizziness unusual weight-gain, fever are serious and immediate medical help should be taken. New born babies should be kept warn1 dnd exclusive breast-feeding should be given. Imrnunisation like BCG, DPT, Polio, Measles and Vitamin A supplementation should be given before age of one year:

When baby get

diarrhea,'^^^ and home available foods should be given.

Baby with ARI should be taken to referral center or hospital. Extra dos.es of polio during Pulse Polio programme should be given which will help in eradicating polio. boys and girls should be educated about family life and All adolesce~it reproductive health. Counseling of adolescent for reproductive health.

All young couple should have access to family welfare services. The problems milst be attended to and counselling must be providcd. Sexually transmitted diseases may be treated and counselling should be provided on practicing safe sex and use of condom for prevention of HIV/AIDS.

3.7 LET US SUM UP


In this unit, you have learnt about Lhe evolution of the National Family Welfare, RCH and CSSM Programme and their functioning in India. Social component of the lanlily welfare programme includes Social Safety Net Scheme, Mahila Swasthya Sangh (MSS), etc.
,
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The components of child survival includes UIP, ORT Programme, Anaemia Prevention and Vitamin A prophylaxis, ARI Control, essential newborn care.

Role of Nurse in National Health Programmes

Attempts for eradication of poliomyelitis, elimination of neonatal tetanus and measles prevention are the historic milsestones in the health care delivery system. Safe delivery and role of nurse in different components of MCH care has also been higldighted.

Check Your Progress 1 1) To eradicate poliomyelitis by replacing the mild polio virus by the vaccine virus. 2) These are referral centres, having facility to deal with emergency obstetrical care. Six to twelve First Referral Units (FRU) are planned to be established in each district adopted under safe motherhood Programme.
Check Your Progress 2
a) Reproductive health - Responsible healthy sexual behaviour - Intervention to, promote safe motherhood

Prevention of unwanted pregn~mcies Safe abortion Pregnancy and delivery services Management of RTI and STD Reproductive health services for adolescent Screening and treatment of infertility, cancer and other gynaecological disorders.

b) Child Health - Essential 'newborn


.

Prevelntion and management of vaccine preventable disease Urban measles campaign Neonatal tetanus elimination Coldchain Polio eradication ARI control progranme Diarrhoea control programme Prevention and control of vitamin A deficiency Baby frikndly hospital initiative Integrated management of neonatal and childhood illness,

Check Your Progress 3 1) To stabilize the population at the level of some 130million by the year 2050 AD. 2) o n the basis of Crude Biah Rate higher than 39 per 1 0 0 population. 3) a) Conventional contraceptive 1Condom is available in different brand names under social marketing scheme.
b) Oral Pill - Steroidal hormones as 'Mala-N' and 'Mala-D', Nansteroidd preparation as 'Saheli'.

c) Intrauterine device - 'Cu-T' and Lippes Loop, d) Permanent method - Vasectomy and Tubectomy. Non scalpel vaseceorny and Laparoscpic tubectomy facility is also available.
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