Maternal & Newborn Guidelines
Content
Operational Guidelines on on
Maternal and Newborn Health
Operational Guidelines on
Maternal and Newborn Health
MESSAGE The National Rural Health Mission (NRHM), has brought a renewed emphasis on strengthening our public health systems and achieving the goal of health for all. Substantial investments have been made in strengthening infrastructure, building capacity of service providers, and ensuring uninterrupted flow of drugs and supplies. These investments are beginning to yield results. Across the country, the Janani Suraksha Yojana has seen unprecedented number of women accessing institutions in the public publi c sector for delivery services. And yet, we cannot afford to rest. Much remains to be done, if we are to meet our national goals of reducing maternal mortality to 100/100,000 and infant mortality to 30/1000. Despite the encouraging improvements and expansion in infrastructure and human resources, issues of inequity in access and poor quality in health care persist. The challenge before us now is to ensure that all women and newborns, no matter where they live, can demand and obtain the service that the NHRM promises. I welcome these operational guidelines as another major effort to address the problem of maternal and newborn mortality. These These operational guidelines should become the basis for ensuring that every single pregnant woman in the nation has a safe delivery and every new born has the best possible chance for survival. The National Rural Health Mission is committed to providing the funds needed to reach these standards nationwide. I call upon programme managers to use these guidelines to plan access to these basic services for even the poorest household and the most inaccesible inaccesible areas. New Delhi 7.4.2010
(Ghulam Nabi Azad)
MESSAGE The National Rural Health Mission has enabled several innovationss to promote people’s access to services. One of innovation the most impressive impressi ve of these is the Janani Suraksha Yojana, Yojana, which has enabled unprecedented increases in institutional delivery across the country. However the term “institutional delivery” should not be reduced to mean any delivery taking place in a building. It must mean the availability of a health team with necessary skills, and equipped with the necessary drugs and equipment who are able to manage a certain level of complications as and when they arise, and take responsibility for reaching them to where it can be managed. Unless pregnant women with complications are managed adequately, institutional delivery by itself would fail to lower maternal mortality ratios. All this is i s true for the prevention of neonatal mortality also. These Operational Guidelines specify the package of services each level of facility would provide and the quality parameters for these. Further proposed is a supervisory structure and an external system of assessment that would enable the planner to ensure that the services guaranteed are actually being delivered. The institutional linkages and community community support needed is also described. This document would help the district planner to prepare a plan that would guarantee every woman a safe delivery. But further it should become a tool for financing the program such that every poor woman gets the support needed to meet her expenses and that every facility and every provider is incentivised in proportion to the work load they are managing. The Ministry is launching these operational guidelines to enable states and districts to develop outcome based plans to reduce maternal and newborn mortality. As a beginning these guidelines would would be used to plan, monit monitor or and support the achievement of NRHM goals in the poorest performing 125 districts of the country. But gradually such planning, based upon well defined service guarantees, clear quality norms, specific local contexts, and differential financing should inform all district health planning pl anning in the country.
New Delhi 7.4.2010
(K. Sujatha Rao)
MESSAGE NRHM initiatives over the last five years at community, institution and management levels have enabled high levels l evels of access to public sector facilities. The Janani Suraksha Yojana has played a large part in empowering and enabling pregnant women to access facilities for safe delivery. Despite these gains, issues of quality access and equity are areas of concern that need to be addressed. The need for care does not cease after childbirth and the emphasis in planning should be on a continuum of care approach that enables care in pregnancy, delivery, for the newborn and post-partum care through a well-planned and effectively executed strategy. The guidelines are designed so as to translate technical strategies into planning processes. The guidelines span strategic approaches and a service delivery framework based on Indian Public Health Standards, human resource development, quality certification and community linkages including the role of the ASHA. These guidelines are part of a larger set of manuals that the Government of India is developing. These would include the training manuals, the supervisors’ manuals, the standard treatment protocols and the quality manual. I hope that the states and districts are able to effectively use these guidelines in developing specific plans to address the issue of maternal and newborn mortality. New Delhi 7.4.2010
(P. K. Pradhan)
Abbreviations ANC
: Antenatal Care
ANM ASHA AWW BCC BEmONC CEmONC CHC EmOC FRU HBNC HIV HMIS IMNCI IMR IUD LBW LSAS LHV MO MoHFW MTP MMR MVA NGO NHSRC NIHFW NRHM
:: : : : : : : : : : : : : : : : : : : : : : : : : :
Auxiliary Midwife AccreditedNurse Social Health Activist Anganwadi Worker Behaviour Change Communication Communicatio n Basic Emergency Obstetric and Newborn Care Comprehensive Emergency Obstetric and Newborn Care Community Health Centre Emergency Obstetric Obstetri c Care First Referral Referral Unit Home Based Newborn Care Human Immunodeficiency Virus Health Management Information Systems Integrated Management of Neonatal and Childhood Illnesses Infant Mortality Rate Intrauterine Device Low Birth Birt h Weight Life Saving Anaesthesia Skills Lady Health Visitor Medical Officer Ministry Minist ry of Health and Family Welfare Medical Termination erminati on of Pregnancy Maternal Mortality Ratio Manual Vacuum Aspiration Aspirat ion Non-Governmental Non-Governmental Organisation National Health Systems Resource Centre National Institute of Health and Family Welfare National Rural Health Mission
NSSK NSV OT PIH PHC PPH PRI RCH SBA SC SHG SHSRC SIHFW
: : : : : : : : : : : : :
Navjaat Shishu Suraksha Karyakram Non-Scalpel Non-Scalp el Vasectomy Operation Operati on Theatre Pregnancy Induced Hypertension Hyper tension Primary Health Centre Post-Partum Haemorrhage Haemorrha ge Panchayati Panchayati Raj Institution Reproductive and Child Health Skilled Birth Attendant Scheduled Caste Self-Help Group State Health Systems Resource Centre State Institute Institu te of Health and Family Welfare
SNCU ST VHND VHSC
: : : :
Sick Newborn Care Unit Scheduled Tribe Village Health and Nutrition Day Village Health and Sanitation Committee Committee Operational Guidelines on Maternal and Newborn Health
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Contents CHAPTER -1: -1: Background, Rationale and Principles of the Guidelines
11
CHAPTER -2: Strategies -2: Strategies for Ensuring Improvements in Maternal and Newborn Health
15
CHAPTER -3: -3: The Service Delivery Framework
17
CHAPTER -4: -4: Supervision and Monitoring
25
CHAPTER -5: -5: Quality and its Certification
27
CHAPTER -6: -6: Making Choices for Safe Delivery
28
CHAPTER -7: -7: Human Resourc Resource e Development
30
CHAPTER -8: -8: Institutional Support Systems and Linkages
32
CHAPTER -9: -9: Private Sector Partners
34
CHAPTER -10: -10: Community Support Systems and Linkages
35
CHAPTER -11: -11: Janani Suraksha Yojana
39
References
42
ANNEXES
43
CHAPTER -1
Background, Rationale and Principles of the Guidelines
1.1. Background: 1.1. Background: Current Status of Maternal and Newborn Health Maternal health is important to communities, families and the nation due to its profound effects on the health of women, immediate survival of the newborn and long term well-being of children, c hildren, particularly girls and the well-being of families. Maternal death and illness have cost implications for family and the community because of high direct and indirect costs, the adverse impact on productivity and the tremendous human tragedy that every maternal or child death represents. Maternal mortality and morbidity indicators reflect not only how well the health system is functioning, but also the degree of equity in public service delivery, utilisation of services, and the social status of women. Every year, in India, 28 million pregnancies take place with 67,000 maternal deaths, 1 1 million women left with chronic ill health, and 1 million neonatal deaths.2 Care for the mother Neonatal mortality in India is about 35/1000 live births (SRS-2008) and accounts for and infant has to 50% of deaths of all children under five. 3 Three quarters of all neonatal deaths occur be provided from during the first week of life, and about 20% take place in the first 24 hours. 4 This is conception to the first also the period when most maternal deaths take place. Thus, the provision of maternal 42 days after delivery and newborn care through a continuum of care approach, ensuring care during critical at the home/community periods of delivery and postnatal period, addresses the needs of the mother and the levels, institutions newborn through a seamless transition from home and village to the facility and back where delivery takes conception till the first place and again at again .5 Care for the mother and newborn has to be provided from conception 42 days after delivery at the home/community levels, institutions where delivery takes home after discharge place and again at home after discharge from the facility. facility. from the facility. High maternal and neonatal mortality is generally ascribed to medical causes. However maternal deaths are higher among Scheduled Castes (SCs) and Scheduled Tribes (STs), 26 and among less educated and poorer families, indicating the importance of social determinants of high mortality.
Sample Registration Survey, 2004-06, Government of India State of the World’s Children, UNICEF, 2009 3 National Family Health Survey Phase 3, (2005-2006) International Institute of Population Studies
1
2
4 5
Indian of Medical Research 2006, (WHO/FCH/CAH/09.02), “Home visits for the newborn child: A strategy Source:Council World Health Organization, to improve survival”, WHO/UNICEF Joint Statement.
Operational Guidelines on Maternal and Newborn Health
11
1.2. Causes 1.2. Causes of Maternal and Neonatal Deaths Neonatal Deaths (%)
6
Maternal Deaths (%)
4 Haemorrhage
Neonatal tetanus
25
42
36
23
38
34
Severe infection
Sepsis
Birth asphyxia
Hypertensive Disorders
Diarrhoeal diseases
Obstructed Labour
Congenital anomalies Pre-term birth
Abortion Other Conditions (e.g. Malaria, Heart disease and Hepatitis)
8
Others
11 5
WHO SEARO Mortality Country Fact Sheet, India 2007 Source: World Health Statistics 2007 24
5
SRS-2001-03Ref 17
Social determinants of maternal and neonatal mortality The underlying social, political and economic conditions also contribute to maternal and neonatal deaths, and these require a wider range of interventions, beyond the direct purview of the health sector. 1. Economic and Social Status: Women in poor households have reduced access to nutrition,
rest, health education and healthcare – all of which are essential for safe pregnancy. Such women are also likely to be more malnourished and anaemic with greater risk of dying as a result of haemorrhage. 2. Early Marriage and Childbearing: Childbearin g: Women who get pregnant young tend to develop more
complications during pregnancy and delivery and are more likely to die. Neonatal mortality mor tality is also higher among young women. Risk of complications is also higher among women whose pregnancies are not adequately spaced, and where there is frequent childbearing. 3. Public Infrastructure Infrastr ucture and Access to Care: The lack of roads and public transport is a barrier
to access. In such areas, the development and therefore density and functioning of both public and private health services is poor. This is a major contributor to maternal deaths.
1
adequate treatment once a woman has arrived at the health facility (poor organisation or lack of skilled doctors and nurses, gaps in supply of equipment, shortfall of blood).
the problem (lack of awareness of danger signs, low status of women, no control over resources, lack of decision making) and deciding to seek care (health facility inaccessible, fear of costs, fear of poor treatment). Delay 2: Delay in reaching the
health facility (high costs, lack of transportation, poor roads).
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Operational Guidelines on Maternal and Newborn Health
3
Delay 3: Delay in receiving
Delay 1: Delay in recognising
2
1.3. Rationale 1.3. Rationale for Guidelines This manual is designed to help programme managers at district and state level, to plan, implement and supervise the delivery of services that would guarantee a safe childbirth for every mother.
ns: tion ues tio y qu g ke y q ing win the f ollo w ers th we his manual ans w T Th viision of care the pro v ying th les underl yi the principles t are th ha t Wh • W borns? wb hers and ne w th f or mo t ternal and e ma te ve to impro v egies to te tra t y s tr he ke y th t are t Wha t • Wh th? born heal th wb ne w to ailable to va to be made a v vices to the package of ser vi t is th ha t Wh • W ensure saf e pregnanc y y and chil ild dbir th th, and care of t th he born? wb ne w ailable? va to be made a v vices to these ser vi here are th Wh • W f or the human resources and skills needed t are th ha t Wh • W here can wh w and w vel? Ho w t each le ve vices a t viiding ser vi pro v p? t up buil t u lls can be bu hese skills t th t and supplies are needed ure, equipmen t tu truc t t inf ras tr Wha t • Wh vices? these ser vi vide th o pro vi t to y t y kages and communi t ink tional lin tu ti ti tu the ins ti t are th ha t Wh • W hese th t t to suppor t i ves needed to t ve i tia ti tion in tia lisa ti mobilis ser vi vices? es? vice these ser vic vise th i tor and super vi we mon to o we do w d • Ho w y and i t y the qual t tion f or th i tu ti t tu y y each ins ti tif e cer ti we w do w • Ho w vides? t prro vi vices i t p package of ser vi viision forr the pro v vailable fo iall packages a va t he financia t are th ha t Wh • W vel? ach le ve ea t e vices a t of ser vi
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1.4. Principles 1.4. Principles of Organising Care for Maternal and Newborn Health
1. Every woman must be enabled to have her childbirth with a Skilled Birth Bir th Attendant (SBA), in a setting of maximal dignity, comfort, and care.
2. Since life threatening complications may arise in any delivery, every effort must be made for all women to deliver in an institution where most maternal and newborn complications can be promptly and effectively managed, and with the means to transport a patient safely and quickly to an institution where complications that require surgical care and blood transfusion can also be managed.
3. Where a delivery is known to have much higher risk of complications even before the onset of labour, e.g. an adolescent mother or a previous Caesarean, every effort must be made so that the delivery takes place in an institution where surgical care and blood transfusion for managing emergencies is available.
5. Every newborn must be provided with appropriate care and support from the moment of birth. This includes initiation of breastfeeding, keeping the baby warm, identifying illnesses or risk including low birth weight, resuscitation where indicated, access to referral care at an institution, and close follow-up at home for 28 days after birth.
4. Every mother must be provided with postnatal care that ensures support to her in this period, identifies complications and arranges for referral when required. This care is preferably institutional in the first 48 hours, with home based follow-up for a 42 day period thereafter.
7.
6. The public health system must hold itself accountable to provide skilled human resources, infrastructure and equipment, institutional linkages and supervision needed to ensure that these services guarantees for safe maternal and newborn health are realised.
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Operational Guidelines on Maternal and Newborn Health
A grievance redressal mechanism must be in place which should receive reports of any failure to deliver the services that are certified as available in a particular facility and take appropriate action, and provide feedback to the complainant and public.
8. Every maternal or newborn death must be accounted for and investigated so as to detect system gaps and to increase accountability. 9. The provision provisio n of maternal and newborn care should be based on a ‘continuum of care’ approach that covers the entire period of pregnancy, delivery and postnatal period, and the needs of the newborn, through a seamless transition from home and community to the facility, referral institutional care where needed, and back again to the home.
CHAPTER -2
Strategies for Ensuring Improvements in Maternal and Newborn Health
The key strategy is to ensure care of the pregnant mother and newborn during the period from conception up to 42 days of delivery. A more comprehensive approach to reducing maternal and neonatal mortality also encompasses encompasses the period of adolescence among girls to ensure that they are well-equipped for pregnancy and childbirth and the provision of family planning to ensure that no pregnancy occurs before the age of 21 years. The strategies for maternal and newborn health include: i nclude:
2.1. Provision 2.1. Provision of Quality Antenatal Care All women must have access to a package of antenatal services provided in the community or at the facility by a provider who is skilled and who has the necessary equipment and supplies.
2.2. 2.2. Ensure Ensure Access to a Skilled Birth Attendant A Skilled Birth Attendant (SBA) is a professionally qualified individual who can handle normal pregnancies and deliveries, deliveries, equipped with skills to provide essential newborn care, identify obstetric and neonatal emergencies, manage complications as per their defined competencies, and undertake timely referral to a higher centre where comprehensive obstetric care can be provided.
2.3. Functional Facilities to Pro Provide vide Institutional Delivery Care for pregnancy, childbirth and newborn can be provided at any of the three facility levels shown in the box:
Definitio initions ns Def Institutional Delivery (Comprehensive Level-FRU): All complications managed
3 l including C-Section and blood transfusion, i.e. Comprehensive Emergency e Obstetric and Newborn Care (CEmONC) provided at equipped public and v e private hospitals. The public and private hospitals would also be equipped L
with Neonatal Stabilisation Unit U nit and Sick Newborn Care Unit (SNCU). 2Institutional Delivery (Basic Level): Delivery conducted by a skilled birth attendant in a 24x7 l PHC level (PHC or CHC with Basic Emergency Obstetric and Newborn Care (BEmONC) or in e v a private nursing home with equivalent facilities) having Newborn Corner and Stabilisation e L Unit. 1 Skilled Birth Attendance: This refers to a delivery conducted by skilled birth attendant in all Sub-Centres l and in some Primary Health Centres (PHCs) which have not yet reached the next level of “24 x 7 PHC”. e v Newborn Corner in all facilities. Home deliveries assisted by a skilled birth attendant would also be e L included under safe deliveries at this level. Operational Guidelines on Maternal and Newborn Health
15
The point is simple – any delivery delivery that happens within the four walls of a health institution is not to be called institutional. It must provide a level of care as specified. Private sector care should also be grouped along these categories. categories.
2.4. Facility Based Newborn Care This should be given at the time of birth as appropriate to each of the three levels – Sick Neonatal Care Unit at district hospitals, Newborn Stabilisation Units at all institutional delivery facilities, whether comprehensive comprehensive or basic, and Newborn N ewborn Care Corner at all facilities.
2.5. Home Home Based Newborn Care and Postnatal Care 2.5. This should be provided through a series of visits. (First two days of care should be given at the facility where institutional delivery took place.) At home, care should be provided within 24 hours of delivery for the newborn by a trained community health volunteer who may be an Accredited Social Health Activist (ASHA) or an Anganwadi Worker (AWW) or other health worker as appropriate to that context and who is a resident of that habitation.
2.6. Referral Linkage and Transport This is for access to emergency services. services. The ideal situation is where every mother delivers in an institution with access to a referral centre within one hour, in case of complications requiring surgery and blood transfusion. District health plans must conform to a roadmap to reach this ideal, respecting and supporting the wishes of families at every stage.
2.7. Behaviour Change Communication (BCC) This is carried out by ASHA and other health workers to ensure care in pregnancy and for the newborn, recognition of complications and their danger signs, birth bir th planning, and choosing a safe site for delivery.
2.8. Involvement Involvement of Women’s Groups and Community Mobilisation 2.8. This is required to promote key messages for delaying age at marriage, spacing, delaying age at first birth, ensuring gap of at least three years between pregnancies and management of unwanted pregnancies. To ensure delivery of these services, the programme should define a) the package of services to be delivered at each level, b) the quality of standards and protocols for these services, c) the minimum skills the service providers would have to be certified for, d) the process of certification of both facility and of service provider, and e) the institutional linkages and community mobilisation that is needed. This service delivery framework is given in the next chapter.
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Operational Guidelines on Maternal and Newborn Health
CHAPTER -3
Level 1 SBA Level
The Service Delivery Framework Framework
3.1
Antenatal Care (minimum 4 ANCs including registration) Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre, PHCs
PHC-Basic Obstetric and Neonatal
FRU-Comprehensive Obstetric
not functioning as 24x7 and home
Care (24X7 PHCs, CHCs other than
and Neonatal Care (DH, SDH, RH,
deliveries conducted by SBA)
FRUs)
selected CHCs)
ANC session should include:-
All in Level 1 + blood grouping &
All in Level 1 + blood cross matching +
Re Registration gistration (within 12 12 weeks) weeks)
Physical examination + weight+ weight+ BP + abdominal examination
Identification and referral for danger signs
Ensuring consumption of at least 100 IFA tablets (for all pregnant women)/200 (for anaemic women). Severe anaemia needs referral.
Rh typing, Wet mount (saline/KOH), management of severe anaemia RPR/VDRL Management of complications in Management and provision of pregnancy referred from Levels 1 and 2 all basic obstetric & newborn care including management of complications other than those requiring blood transfusion or surgery
Essential lab investigations (HB%, urine for albumin/sugar, pregnancy test)
TT immunisation (two doses at interval of one month)
Counselling on nutrition, birth preparedness, safe abortion, Family Planning and institutional delivery
Assured referral linkages for complicated pregnancies and deliveries
Linkages with nearest nearest ICTC/ ICTC/
PPTCT centreand fortesting voluntary counselling for HIV and PPTCT services
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3.2 Intranatal Care
Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre, PHCs
PHC-Basic Obstetric and Neonatal
FRU-Comprehensive Obstetric
not functioning as 24x7 and home
Care (24X7 PHCs, CHCs other than and Neonatal Care (DH, SDH, RH,
deliveries conducted by SBA)
FRUs)
selected CHCs)
All in Level 1 + All
All in Level 2 + availability of
Normal delivery with use of partograph
Active management of third stage of labour
Availability of following services round the clock Episiotomy and suturing cervical tear
Infection prevention
Identification and referral for danger signs
Assisted vaginal deliveries like outlet forceps, vacuum
following services round the clock: Management of obstructed labour
Surgical interventions like Caesarean section
Comprehensive management
Pre-referral management obstetric emergencies, e.g.for eclampsia, PPH, shock Assured referral linkages with higher facilities
Essential newborn care will include:
Neonatal resuscitation
Stabilisation of patientse.g. with obstetric emergencies, eclampsia, PPH, sepsis, shock Referral linkages with higher Referral facilities
Essential newborn care as in Level 1+
Antenatal Corticosteroids to the mother in case of pre-term babies to prevent Respiratory Distress Syndrome (RDS)
Warmth
Infection prevention
Support for initiation of breastfeeding breastfee ding within an hour of birth
Screening for congenital anomalies
Weighing of newborns
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Operational Guidelines on Maternal and Newborn Health
Immediate care of LBW newborns (>1800 gm)
Vitamin K for premature premature babies
of all obstetric emergencies, e.g. PIH/Eclampsia, Sepsis, PPH retained placenta, shock etc. In-house blood bank/blood storage centre
Referral linkages with higher Referral facilities including medical colleges
Essential newborn care as in Essential Level 2 +
Care of LBW newborns <1800 gm Care of sick newborns
Vitamin K for premature premature babies
3.3 Postnatal and Newborn Care
Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre, PHCs
PHC-Basic Obstetric and Neonatal
FRU-Comprehensive Obstetric
not functioning as 24x7 and home
Care (24X7 PHCs, CHCs other than and Neonatal Care (DH, SDH,
deliveries conducted by SBA)
FRUs)
RH, selected CHCs)
All in Level 1 + All
All in Level 2 + All
Minimum 6 hrs stay post delivery
Counselling for Feeding, Nutrition, Family Planning, Hygiene, Immunisation and postnatal check-up
Home visits on 3rd, 7th and 42nd day, for both mother and baby. Additional visits are needed for the newborn on day 14, 21 and 28. Further visits may be necessary necessary for LBW and sick newborns.
Timely identification of danger signs and complications, and referral of mother and baby
Newborn Care
Warmth
Hygiene and cord care
48 hours stay post delivery and all the postnatal services for zero and third day to mother and baby
Timely referral of women with postnatal complications
Stabilisation of mother with
postnatal emergencies, e.g. PPH, sepsis, shock, retained placenta Referral Referral linkages with higher facilities
Clinical management of all maternal emergencies such as PPH, Puerperal Sepsis, Eclampsia, Breast Abscess, post surgical complication, shock and any other postnatal complications such as RH incompatibility etc.
Newborn Care as in Level 2 + in
district hospitals through Sick Newborn Care Unit (SNCU) Management of complications
Newborn Care as in Level 1 + Newborn
Stabilisation of complications and referral
Care of LBW newborns <1800 gm
Establish referral linkages with higher facilities
Care of LBW newborns >1800 gm
Exclusive breastfeeding breastfeeding for 6
months Identification, management and referral of sick neonates, low birth weight (LBW) and pre-term newborns
Referral services for newborns <1800 gm and other newborn complications
Management of sepsis
Referral linkages for management of complications
Care of LBW newborns <2500 gm
Zero day immunisation OPV, BCG, Hepatitis B
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3.4 Safe Abortion Services as per MTP Act Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre,
PHC-Basic Obstetric and Neonatal Care
FRU-Comprehensive Obstetric
PHCs not functioning as 24x7 and (24X7 PHCs, CHCs other than FRUs)
and Neonatal Care (DH, SDH, RH,
home deliveries conducted
selected CHCs)
by SBA)
Counselling C ounselling and facilitation for safe abortion services
Same as in Level 1 +
Same as in Level 2 +
Essential – MVA up to 8 weeks
Desirable first trimester services (up to 8 weeks) as per MTP Act and Guidelines
Second trimester MTP as per MTP Act and Guidelines
Management of all post abortion complications
Post abortion contraceptive contraceptive counselling
Referral linkages with higher Referral centre for cases beyond 8 weeks of
pregnancy up to 20 weeks Treatment of incomplete/inevitable/ spontaneous abortions Medical methods of abortion (up to 7 weeks of pregnancy) with referral linkages
Management nt of RTI/STIs 3.5 Manageme Counselling, prevention and referral
All in Level 1 +
Identification and management of
All in Level 2 + ICTC (desirable)
PPTCT at district hospitals
RTI/STIs Referral linkages with ICTC
3.6 Family Planning Services as per the FP Guidelines Emergency contraception contraception pi pills lls
Counselling, motivation for small family norm, distribution of condom, oral contraceptive pills, IUD insertion
All in Level 1 + All Desirable - Male Sterilisation including Non-Scalpel Vasectomy Vasectomy + Tubectomy
All in Level 2 + All Male Sterilisation including Non-Scalpel Vasectomy
Female Sterilisation (Mini-Lap and Laparoscopic Tubectomy)
Referral Ref erral linkages for sterilisation
Follow-up services for
contraceptive acceptors, including post sterilisation acceptors
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Operational Guidelines on Maternal and Newborn Health
Management of all complications
3.7 Making Home Deliveries Safer Even while we continue to promote institutional delivery, we have a “responsibility to help families choosing to give birth at home to have a safe and clean labour, delivery, and postpartum experience”. The single most important component of making a home delivery safe is ensuring that a SBA attends the delivery. The second most important component is to have a plan for referral if complications arise. A birth preparedness plan must be made during the antenatal care visit. In the Maternal and Child Health card, the birth plan includes contact information, knowledge of danger signs, transport arrangement, financial arrangements, telephone numbers for potential last minute access to the referral facility etc.
I. Symptoms or signs that identify a woman at risk who should not deliver at home Danger signs – Any bleeding in pregnancy, generalised swelling of the body and seizures,
high fever. fever. During previous pregnancy – – Caesarean delivery, poor obstetric history with previous foetal
loss; in this pregnancy, premature labour or malpresenting foetus, sev severe ere anaemia, medical disorders such as heart disease, diabetes, tuberculosis, hepatitis or jaundice.
II. Checklists Checklists for preparation of home birth
?
i) Checklist for Family: Families of women who have
made up their mind on a home delivery should be given a checklist (Annexe I-B), at least a month before the due date, to help ensure they have everything ready for a safe home birth. The nurse/midwife or ASHA should visit the home with the checklist at least two weeks before the expected date of delivery deli very to make sure that the family is prepared. The family/ ASHA should call the ANM at the onset of labour.
? ?
ii) Checklist for the A NM : The ANM must be informed
and be present with her kit (Annex 1-B) 1-B) during labour and delivery to provide skilled attendance at birth, and ASHA to help provide care for the newborn.
iii) The Safe Home Delivery Protocol: Protocol: Is described in
the MoHFW Guidelines for ANM, LHV, Staff Nurses 6
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3.8 The Infrastructure and Support Services Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre,
PHC - Basic Obstetric and
FRU-Comprehensive Obstetric
PHCs not functioning as 24x7 and
Neonatal Care (24X7 PHCs, CHCs
and Neonatal Care (DH, SDH, RH,
home deliveries conducted by SBA)
other than FRUs
selected CHCs)
Minimum 6 beds, stay - 48 hrs (uncomplicated delivery)
Minimum 30 beds, stay - 48 hrs (uncomplicated delivery), 3-7 days (complicated)
i) Minimum number of beds
Facility for staying at least 6 hrs: In home deliveries, SBA should be available for 2 hours after child birth. ii) Human resource
Minimum two ANMs (trained as SBA) of which one is available at the headquarters most of the time. (In PHC, it could be trained nurses)
1-2 MO with BEmOC training,
trained in F.IMNCI
As in Level 2 +
Obstetrician (degree/diploma/ MBBS with EmOC training)
3-5 Staff Nurses/ANM with SBA training and NSSK
(round-the-clock presence) Other supportive staff
For home delivery, the SBA would
An anaesthetist (degree/ diploma/MBBS with LSAS training)
Paediatrician (degree/diploma/ MBBS trained in F.IMNCI)
need assistance of a team of two or three women of which at least one could be ASHA, dai, AWW or any
For blood transfusion services: A lab technician with skills in blood transfusion or a MO trained to provide these services
community level health worker and another could be a Self-Help Group (SHG) member or any community volunteer, to help with ancillary
Nursing Care – At least 9 more
functions.
nurses to work on 8 hour shift duties and provide quality nursing care, in labour room (3), neonatal stabilisation unit (3), OT and other areas of these hospitals (3). DH-SNCU would require even more. iii) Labour room
Labour table and newborn care
All in Level 1 +
corner to provide immediate care for all newborns. For drugs, equipment and essential drugs
Vacuum extractor extractor + newborn corner + stabilisation unit where most sick and LBW newborns are
(see Annexe 1-A)
stabilised. For drugs, equipment and essential drugs (see
At home – clean surface and surroundings
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Operational Guidelines on Maternal and Newborn Health
Annexe 1-C)
Same as in Level 2 +
Sick Newborn Care Unit. For drugs, equipment and essential drugs (see Annexe 1-E)
Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre,
PHC - Basic Obstetric Obstetr ic and
FRU-Comprehensive Obstetric
PHCs not functioning as 24x7 and
Neonatal Care (24X7 PHCs, CHCs
and Neonatal Care (DH, SDH, RH,
home deliveries conducted by SBA)
other than FRUs
selected CHCs)
iv) Functional Operation Theatre (OT) and Blood Transfusion Facility
Not required
OT for minor procedures including for sterilisation and MVA
24x7 functional OT with facility for Caesarean section
Blood Bank/Blood Storage Unit
v) Drugs and equipment equipment
See Annexe 1-A and 1-B
See Annexe 1-C
See Annexe 1-D and 1-E
Diet provided by facility – hot cooked meals
Diet provided by facility – hot cooked meals
vi) Diet provision
None: Clean safe drinking water. Boiled and cooled water. Home food brought by patient’s family vii) Transport Transport
Should be linked to a transport service that reaches within 30 minutes and transports patient
to referral centre.
Should have an ambulance that could transfer patient to referral centre within an hour.
Should be able to pick up and drop patient as required. Should be available on 24x7 call basis.
Should be able to pick up patient from the village.
Transport may be needed for ANM to reach the home of pregnant women.
Should drop patient back home in specific category of cases.
viii) Water Water and electricity electricity
Assured water supply that can be drawn and stored locally. Electricity supply linked to main lines or adequate solar source, inverter or back-up generator as appropriate.
Piped 24 hour water supply and 24x7 electricity link with generator back-up
Same as in Level 2
No drafts; some simple ways
Minimum required ventilation,
Same as in Level 2+
of keeping room warm and ventilated. Insect proofing required.
lighting and warmth. Minimum lighting measured in lux. Insect proofing mandatory.
Controlled temperature in intensive setting such as SNCU and OT.
ix) Lighting, warmth and ventilation
Operational Guidelines on Maternal and Newborn Health
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Level 1 SBA Level
Level 2 Institutional (Basic Level)
Level 3 Institutional (Comprehensive Level)
Delivery by SBAs (Sub-Centre,
PHC - Basic Obstetric Obstet ric and
FRU-Comprehensive Obstetric
PHCs not functioning as 24x7 and
Neonatal Care (24X7 PHCs, CHCs
and Neonatal Care (DH, SDH, RH,
home deliveries conducted by SBA)
other than FRUs
selected CHCs)
One One perso person n on on secu securit rityy duty duty at all times. No stray animals allowed in premises. Compound wall mandato man datory* ry*..
Security round-the-clock through an outsourced or adequately staffed internal arrangement. Compound wall wa ll mandatory. ma ndatory.*
x) Security
Prov Provide ided d by by family family an and d atte attende nders rs
xi) Sanitation and hygiene
One toilet for patient use that is kept clean at all times. Fresh sheet for every patient, fresh sheet for every day for every bed in use and as needed.
At least two toilets for patient use and two bathing and washing spaces.
At least six toilets and three bathing spaces for patient use.
Rest same as in Level 2, but assured laundry service must be in place.
Separate spaces for women
Fresh sheet for every patient.
Laundry service desired. xii) Infection prevention6
Hand washing as per protocol. Use of disposable gloves, gl oves, use of disinfectants, clean sheet, new blade for cord cutting, sterilised cord ties, In facility – autoclaving/ autoclaving/ boiling of instruments and colour
Same as in Level 1 +
Same as in Level 2
Autoclave, colour coded bins
coded bins. xiii) Waste management25
Hub-cutter, puncture proof boxes for needle disposal, deep burial of placenta
Same as in Level 1
Same as in Level 1
Deep burial of placenta and all blood and tissue fluid stained
xiv) Rest facilities
Not needed
Relative/companion waiting and utility space needed Birth waiting homes in institutions for families residing in remote areas with poor road connectivity
* Overcrowding of wards to be prevented.
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Operational Guidelines on Maternal and Newborn Health
For ASHAs, birth companion and relatives; separate toilets/kitchen, needed.
CHAPTER -4
Supervision and Monitoring
In addition to the supervisory structure that exists in the state government system, the following additional supervision mechanisms need to be put in place, organised organised at three levels: Block, District and State levels.
4.1. Block Block Level Supervision 4.1. Designation
Responsibilities
Skills Supervisor
Ensures that all nurse-midwife service providers have the necessary skills through on-the-job mentoring. Ensures that protocols of care built up for the services at each level are followed, and
Profile
A nurse-practitioner
Or a nurse recruited and trained for the necessary competencies.
all service providers have necessary skills.
Guides and ensures that all existing Lady Health Visitors (LHVs) undertake clinical supervision in accordance accordance with protocols.
Ensures that all facilities and institutions in the block are certified for quality which includes security, safety and comfort of pregnant women and newborns.
Quality Supervisor
Provides the necessary logistic and organisational support to improve facility level quality and management processes.
Builds up community level linkages to
ensure demand generation. Trains all existing supervisors.
Block Level Accounts Manager
Ensures that all payments made at block and sub-block levels are accounted for in a timely manner and open to public scrutiny. Ensures that all facilities and providers making payments maintain proper accounts.
The existing supervisors (male or female), could be selected for this purpose.
Alternatively, a fresh management graduate willing to be trained for the position could be selected.
Existing block accounts manager if in place.
Alternatively, a contractual accountant could be recruited for this purpose.
Supervisors would have a handbook with both checklists and protocols. A dynamic supervisory team would play a key role in changing the current work ethics and institutional culture.
Operational Guidelines on Maternal and Newborn Health
25
Main Indicators at Block and District Level Pregnant Woman
Newborn
% of pregnancies registered as against expected expected
% of deliveries deliveri es attended by SBA at each level
% of ANCs registered within 12 weeks
% of newborns weighed % of newborns who were LBW
% of newborns admitted and managed for complications
% of complicated deliveries attended
% of complications identified and appropriately treated by diagnosis: severe anaemia, haemorrhage, prolonged/obstructed labour, hypertension in pregnancy, pregnancy, puerperal sepsis
% of newborns breastfed within the first hour % newborns resuscitated
% of stillbirths and neonatal deaths
% complication referred
Caesarean section rates
Family Planning
Appropriate family planning indicators as per the HMIS Deaths
Reports of still births, neonatal deaths, maternal deaths and causes causes Maternal and neonatal death autopsy reports
Note: Only those indicators required by the national level based on HMIS guidelines would be reported up. The remaining indicators are to be used for planning and management purposes.
Processes of Supervision Periodic review meetings Monthly analysis, validation and feedback of HMIS data
Facility visits: using supervisory protocols
Training: raining : on-the-job, on-the-j ob, refresher and supplementary
4.2. District District Level Supervision 4.2. The number of supervisors needed at the block and district levels depends on the number of facilities providing delivery services. One skill supervisor and one quality supervisor for 10 facilities is adequate. If there are more than 50 facilities in a district, including sub- centres where institutional deliveries take place, then another set of district level supervisors will be required. This could be one full time nurse tutor or one full time quality supervisor. supervisor. In addition, the Assistant Chief Medical Officer or RCH officers could provide support.
The quality supervisors and programme officers would be responsible for the facility support and quality certification of each of these facilities. They would also manage the grievance redressal cell which would include i nclude non-official members.
4.3. State State Level Supervision 4.3. Quarte rly review meetings would be held by the state Secretary or the Mission Director, with Quarterly representative of Ministry of Health and Family Welfare (MoHFW) invited. A quality certification body of five persons would organise and supervise the process of quality certification of facilities. This could be located in a Quality Assurance Assurance Cell, wherein professional bodies are represented. The Training Training and Skills Coordination team located in the State Institute of Health and Family Welfare (SIHFW) or other suitable bodies with guidance from NIHFW would monitor, support and ensure the performance and outcomes of the nurse-supervisors in terms of skills in place and use of protocols.
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Operational Guidelines on Maternal and Newborn Health
CHAPTER -5
Quality and its Certification
5.1. Components 5.1. Components Standards of care for for each each service service that meet meet quality quality requirements.
An authorised authorised certifying certifying team charged with with making the visit and certifying the institution.
A process of verification of the facilities so certified. certified.
A process of withdrawal withdrawal of certification if standards fall fall below the acceptable acceptable norms.
A process of public announcemen announcementt of certification or or its withdrawal.
5.2. Standards Standards of Care 5.2. The areas that should be covered are given in the service delivery framework. The details of these would be given in the supervisor’s supervisor’s handbook. Supportive supervision would be able to grade every facility in terms of the package of services it provides, the quantity of services it provides and the quality of each service provided. Onc Once e the service is ready for inspection and certification, the supervisors should inform the certifying authority.
5.3. Authorised Certification on Team Team 5.3. Authorised Certificati The current quality assurance body could be the certification team with one consultant added in by the Mission Director of the state and another nominated by the Mission Director at the national level. In the district quality assurance team, the district would specify three persons selected as per guidelines that are available and train them for this purpose. A checklist and guide manual for certification should be made available. The members of this team should be paid on a per visit basis.
5.4. 5.4. V Verifying erifying Process Process About 5% of facilities in each district should be verified by a second body. In case of gross errors in certification, the composition and conduct of the certification team should be reassessed and changed where needed.
5.5. Withdrawal Withdrawal 5.5. Withdrawal can be initiated in response resp onse to a report from the facility itself, or from the supervisor, or the certifying or verifying verifyi ng team or in response to a pub public lic grievance of denial which was investigated and found to be valid. The same authority as signs the certification would sign its withdrawal.
5.6. Public Announcement 5.6. Public Notices would be put up in the facility and panchayat offices. Information must be passed on to the ASHAs and service providers of the facilities below the institution level who refer cases to it. In addition, it could be announced as a news item or advertisement in the local newspaper with the largest circulation in that district. Operational Guidelines on Maternal and Newborn Health
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Making Choices for Safe Delivery
CHAPTER -6
6.1. Choices Before the District Planner Given below is an example of district planning for safe delivery for all pregnant women, applying the principles and strategies discussed earlier. This focuses on prioritising delivery of good quality reproductive and child health services, while progressively pr ogressively moving towards full Indian Public Health Standards (IPHS). District Population: Population: 20,00,000: Birth rate: 27/1000 Expected Annual deliveries: 54,000: Monthly D Deliveries: eliveries: 4,500 Blocks: 10 - One with DH, two with a CHC and seven with a block PHC District Plan Target: Target: 100% safe deliveries in a three year time period
Institutional Comprehensive Level (providing CEmONC services) Strengthen the District hospital, to manage 600 deliveries per month, of which at least half are expected to be complicated, referred from lower level institutions. The majority of the normal deliveries would come from the nearby peri-urban areas.
This load of complicated and normal deliveries can also be shared by one private health facility that provides this level of service.
600
Strengthen and upgrade two CHCs to this level of service provision. These
could manage 200 deliveries each per month. About half are expected to be complicated cases.
400
Strengthen the remaining seven block PHCs and upgrade 11 APHCs (out of about 40 in the t he district) to Institutional Basic level (24X7 PHCs)
Potential to enter into partnerships with two private health facilities, which provide this level of service to share the caseload.
These 20 institutions would manage a total of 2,500 deliveries per month, or about 125 deliveries each per month, which would be mostly normal deliveries.
These institutions would have the capacity to manage selected complications and stabilise other complications for onward referral if
District Hospital CHC/FRU and Pvt. Hospital
Institutional Basic Level
Institutional Basic Level (providing BEmONC services)
Institutional Comprehensive Level
2500 24 X 7 PHC + Pvt. Nursing Home
Caesarean section and blood transfusion are required.
SBA Level
28
SBA Level
Strengthen 50 of the 400 sub-centres of the district and some of the remaining APHCs to be able to attend to at least 1000 deliveries per month.
These facilities would be selected from areas where the 24X7 PHC is distant, or overcrowded, or poor families in that area are not confident of travelling so far and would prefer the delivery to be nearer home.
While a majority of the deliveries would take place in the facility, the alternative of the ANM attending the delivery at the house could be planned for under appropriate circumstances.
Operational Guidelines on Maternal and Newborn Health
Depending upon the specific context context in each district, the number of deliveries in each category and the choice of facilities to upgrade would differ.
1000 Sub-Centre and other APHC Deliveries by ANM
6.2. Decisions People Make Woman’ Woman’ss choice c hoice
If I go to the PHC which is open 24 hours, I will be cared for and can rest for two days. Also, if there is any surgery needed, they can rush me to the big hospital quickly.
Where should I go
for a safe delivery?
If danger signs or complications develop before the delivery, deli very, I wi willll need ttoo go to the big hhospital ospital straight away, but I hope that does not happen. I will also need to ensure that I have an escort, maybe the ASHA, to accompany me, and that someone is taking care of the children and things at home.
Birth Micro Plan of ASHA/ANM/AWW
If she has any danger signs or complications, I will ask her to go to the CHC or DH when her delivery is due. I must also make arrangements to ensure that the transport transpor t is rea ready dy and avail available able at that time.
I help every family with a pregnant woman to make a birth plan.
If she has no complications, I will counsel her to go to the 24X7 PHC, PH C, and fo forr this too, I mu must st ensure that transportt arrangem transpor arrangements ents are made in titime. me.
But if she and her family do not want to go that far and the 24X7 PHC is crowded, I will advise her to go to the nearby near by sub-ce sub-centre ntre where two ANMs aare re trained to conduct deliveries and one of them is always there. For some women, wo men, fami family ly circ circumstances umstances and bel beliefs iefs make even going to the sub-centre dif�cult. I will then get the th e ANM to com comee to her house, and will assis assistt in the preparations needed, after counselling that a safe delivery in this situation may not always be possible.
Operational Guidelines on Maternal and Newborn Health
29
Human Resource Development
CHAPTER -7
7.1. The Key Issues Getting adequate number of skilled providers in place including leveraging of partnerships.
Ensuring that the skills of of the providers are adequate to deliver quality services.
Ensuring that that there is a positive workforce environment and supportive supportive supervision. supervision.
Ensuring that that there is human human resource resource planning for for managers managers and and supervisors. supervisors.
The service delivery framework specifies the numbers and qualifications of the service providers.
7.2. Human 7.2. Human Resource Requirements, Skill Requirements and Training The table below specifies the skill level required and the training that has been prescribed to achieve this level. Facility
Minimum human resource requirements
Sub-Centre
Minimum tw two ANM should have the skills of a SBA ANMs (trained as SBA) of which one is available at the headquarters most of the time.
21-day SBA training module. May be integrated with: IUD insertion training NSSK training HBNC supervision
Two medical medi cal officers Three staff nurses or ANMs
The SN/ANMs should have skill levels at least of SBA and trained in NSSK. In addition, medical officers and any other staff involved in service provision should have
For SN/ANMs: As above Post basic nurse practitioner training. For Medical Officers: Obstetri c Basic Emergency Obstetric Care (10 days BEmONC training) F.IMNCI + NSSK (11+2 days) Safe abortion/MTP training NSV skills
skills of basic emergency obstetric care and essential and sick newborn care.
Institutional - Basic
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Operational Guidelines on Maternal and Newborn Health
Skill Ski ll requir requireme ements nts Trai rainin ning g requi required red
Management of Childhood Illnesses In which case, training period would be of 25 days or longer.
Conventional/mini-lap training +
Facility
Minimum human resource requirements
Skill Ski ll requir requirem ement entss Trai rainin ning g requ require ired d
Institutional Comprehensive
One Obstetrician/ Gynaecologist One Anaesthetist One Paediatrician or MBBS doctor trained in above
Skills to manage surgical obstetric emergencies, blood transfusion and neonatal emergencies. If
16 weeks short-term training courses for medical officers on emergency obstetrics (EmOC), 18 weeks for life saving anaesthesia skills (LSAS) and 4 weeks course for paediatric skills.
skills + four other doctors and nine nurses. One lab tech trained for blood transfusion support
specialists are not available, medical officers in these specialist skills can be trained.
Integrate/add on with: Safe abortion/MTP training Mini-lap and NSV training Nurses trained as described earlier.
Home Based Level
ASHA or other Skills to make community health a difference in volunteer home visits in the neonatal/postpartum period
15 days on home based care– assuming induction is over. Otherwise 25 days.
7.3. 7.3. Positive Positive Workforce Environment and Supportive Supervision Service providers should feel feel supported supported to stretch themselves and take the risks that are necessary to save lives. An environment where there are rewards and incentives for good performance and extra work helps. Social recognition and recognition from peers and superiors also helps.
Periodic on-the-job visits and opportunities to learn learn provided by a team of supervisors supervisors is also central to improved performance. During supportive supervision visits, the supervisor assists the service provider in her tasks, follows up to see that gaps in supplies or infrastructure are bridged, provides training and encouragement as needed. The supervisor follows a checklist to ensure that every skill is rehearsed, every protocol is understood and followed, all the inputs are in place, and all processes and outputs
recorded appropriately.
7.4. District District Plan and the RCH Programme Manager 7.4. The district needs to have one senior programme manager at the second level to the CMO and one contractual programme manager to ensure that this programme is run according to the plan. The programme manager should be trained and certified in every aspect of training and planning for this programme. He/She should ensure that every facility follows appropriate protocols of care and is monitored and supported to do so.
7.5. The State PIP and the State RCH Officer The State PIP must aggregate district human resource needs and training plans, include plans for fulfilling staff shortages and address other related areas such as incentives for retention and good performance, performance, for developing additional training sites. Operational Guidelines on
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Maternal and Newborn Health
Institutional Support Systems and Linkages
CHAPTER -8
8.1. Referral Transport and Referral Facility Linkage All health facilities accredited for safe delivery or institutional delivery should necessarily have have an assured referral transport linkage and an assured referral facility linkage.
8.2. What is an Assured Referral Transport?
I
II
III
IV
A transport service that could become available within 30 minutes and be able to take the woman or newborn to a referral site within one hour.
This may be: a) an ambulance with the facility, b) an ambulance called from the higher facility, facility, c) an ambulance service, or d) a private or commercial transport vehicle.
Communication contact with the vehicle driver directly or routed through a call centre.
The ambulance service should be free of cost at the time of need.
8.3. What is an Assured Referral Facility Linkage? An assured referral facility linkage is a facility which which provides provides management of complications complications including surgical emergencies and blood transfusion (what is termed comprehensive emergency obstetric and newborn care) and which agrees to provide these services on a cashless basis to any patient referred from the referring facility. This may be a public hospital or an accredited private hospital through a public-private partnership arrangement.
The effort should be to have a network of referral centres within one or two two hours of of any facility providing institutional delivery or any sort of skilled birth assistance.
The facility referred to to has been been intimated intimated by phone about the referral referral with a brief history of the patient, so that on arrival the women is received and treatment started immediately. immediately.
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Operational Guidelines on
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8.4. Improved 8.4. Improved Logistics on Drugs and Supplies All the drugs and supplies suppli es needed for provision provisio n of care in pregnancy, whether antenatal, intranatal or postnatal, and whatever the level of care, should be available as per the approved drugs and supplies list, li st, without interruption in each and every facility. facility.
Warehouse: Warehouse: This primarily requires a district warehouse warehouse with a minimum stock of three months of all the drugs and supplies mentioned for each facility. The warehouse should have an adequate inventory management
system. Minor equipment required for these facilities like blood pressure instruments and Sahle’s haemoglobinometers should also be stocked at the district warehouse at a level of 25% of all the facilities requiring it, it , so that as and when they break or under repair, the facility has the required supplies. Every facility should should indent when when their stocks stocks fall below below an estimated three months requirement. Transport Transport of supplies to the periphery should be assured by the district for Sub-Centres Sub-Centres and all facilities without a vehicle to transport the stocks immediately.
Procurement Procurement systems systems must ensure that that drugs and supplies and minor equipment at the district level are replenished as and when the stocks fall below a three month threshold.
8.5. Family Family Planning Programme Linkages 8.5. All maternal healthcare providers should be able to counsel the new mothers and the families on how to plan their family size and the advantages of a small family. Spacing should be advocated for its beneficial effect on the health of the mother and child and also on reduction of MMR and IMR. There is also a need to counsel for delaying the first child where the woman is in her teens or still young, and to space between children. Counselling should also address contraceptive choices so that the family can make the most appropriate contraceptive choice for their context and need. There is also a need to counsel against son preference. Since specialised service providers are few, SBAs must have adequate skills in family planning methods, especially for Intrauterine Device (IUD) insertion to space between children and while waiting for sterilisation. IUD quality and effectiveness has now improved such that it could be the only contraception opted for. Similarly, doctors in institutional delivery settings must also be able to do female sterilisation post-partum or by mini-lap procedure, or a non-scalpel vasectomy vasectomy.. To the extent that the service provider has won the confidence of the mother and her family, and established her credibility, her advice on family planning should be taken seriously and acted on.
Operational Guidelines on
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Maternal and Newborn Health
Private Privat e Sector Partners Partner s
CHAPTER -9
Wherever suitable private providers of care in pregnancy and for the newborn exist, effort should be made to engage with them based on the following principles: The standards of care should be the the same for for private providers providers as they are for the the public facilities. The certification process should also be similar.
Mapping should be done of of all private private providers in a district. Where there are public sector gaps at a given level of service delivery, available private sector partners could be recruited and utilised to fill in service provider gaps.
Where public-private public-private partnerships are opted for, for, care must be taken taken to draft a contract where the costs and quality are specified and monitored, and access to the poor is ensured. There are GoI guidelines that specifically cover cover all these inputs and include the process of accreditation of such facilities.
Not only signing the contract but but the supervisory supervisory structure and programme managers managers specified earlier should be charged with effective contract management. It also needs a state level policy and guidelines for the same.
Payment Payment must be prompt and made with dignity so as to be able to attract and retain the most service oriented and sincere partners.
Special preference preference may may be given to mission hospitals, philanthropic h hospitals, ospitals, public sector undertaking hospitals, NGO run or worker managed hospitals.
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Operational Guidelines on
Maternal and Newborn Health
CHAPTER -10
Community Suppor Supportt Systems and Linkages
10.1. Why 10.1. Why Community Mobilisation? Positive outcomes for maternal, maternal, newborn newborn and child health programmes require require active community participation and support.
Community mobilisation is the process b byy which the community community feels feels enthused and empowered to act. It is the process by which the community gains the knowledge, optimism and organisation needed for action and change.
Marginalised and vulnerable sections sections require more intensive intensive effort effort in the process process of mobilisation and service delivery.
For certain services, services, like replacing unsafe abortion with safe safe abortion services, services, or male sterilisation, demand generation is also required.
Behaviour change change on critical aspects like delaying age of of marriage and age of mothers mothers at first child birth bir th also requires community mobilisation.
10.2. Who/What are the modalities of community mobilisation? Five mechanisms critical to enabling the continuum of care for mother and newborn are: ASHA
Village Health and Nutrition Day
Village Health and Sanitation Committee Committee
Women’s groups of different types – Self-Help Groups (SHGs), mother’s groups etc. The elected representatives of local panchayats.
Operational Guidelines on
35
Maternal and Newborn Health
10.2.1. The ASHA Role of the ASHA: At the village level, the ASHA ASHA plays a major role in building the community’s awareness of their healthcare entitlements, in providing health education, in facilitating the community’s access to essential health services, and in delivering preventive, promotive and first contact curative care. Service Provider Skills: ASHA would be trained in skills to provide a limited package of first
contact care for mothers and newborns, in addition to preventive and promotive services. This actually enables a better realisation of the continuum of care. Provision of essential newborn care for the normal baby whether delivered in an institution or home is well within the purview of a trained and skilled ASHA.
Measurable Tasks for the care of the mother and newborn: The role of the ASHA in
maternal and newborn health is to: 1.
Track rack and and mobilis mobilise e pregna pregnant nt mothe mothers rs to atte attend nd month monthly ly clin clinics ics,, ssuch uch as as the VHND and facilitate access access to antenatal antenatal care services services provided by the ANM.
2.
Prepa Prepare re birth birth prepar preparedn edness ess plans plans for pregna pregnant nt wome women n with with support support from from family members and ANM.
3.
Co Condu nduct ct home home visi visits ts to to the pregna pregnant nt woma woman n to coun counsel sel the the fami family ly on on ante antenat natal al care- especially especially related to nutrition and rest, protection from malaria, alertness to danger signs and complications, and for making the birth plan.
4.
Support Support insti institut tution ional al deliv delivery ery,, in inclu cludin ding g arrang arranging ing for for transp transport ort an and d escort escort to the facility and act as the birth bir th companion if that is needed and possible.
5.
Make Make home home visi visits ts in in the the postn postnata atall perio period d to diagno diagnose se and and ref refer er in case case of complications such as bleeding or infection.
6.
Make Make newbo newborn rn care care visi visits ts (five (five visi visits ts on Days Days 3, 7, 1 14, 4, 21, 21, and and 28, 28, in addi additio tion n to the delivery visit) to promote early and exclusive breastfeeding, ensure that the baby is kept warm, weigh the baby, counsel mother on recognition of danger signs to enable rapid referral in case of illness in the newborn.
7.
Co Couns unsel el on and faci facilit litate ate family family planni planning ng measu measures res as as approp appropria riate te ffor or the the couple.
8.
Support Support the the ANM in updat updating ing the the Mate Materna rnall and and Child Child Heal Health th ccard ard,, jjoin ointly tly issued issued by MoHFW & MWCD.
(List of ASHA competencies is annexed in Annexe 2-D).
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Operational Guidelines on
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10.2.2. The Village Health and Nutrition Day (VHND) An ANM may have anywhere from 4 to 10 anganwadi centres in her area. On one fixed day, every month she visits each of these anganw anganwadis adis which cater to one or more habitations/hamlets or a part of the village. This is referred to as the Village Health and Nutrition Day (VHND), and serves as a platform pl atform for the ANM to provide all outreach services such as ANC, PNC, family planning, immunisation, treatment for sick children and making of blood slides in fever cases. Both the AWW and ASHA support the ANM by mobilising those children, pregnant women and sick persons pers ons in need of care, to attend the th e VHND. In VHND, the provision of immunisation and antenatal care is also undertaken. The ASHA should also help to make it a community event, and make a special effort to ensure that women living in hamlets and those from marginalised communities are reached with services.
10.2.3. The Village Health and Sanitation Committee (VHSC) and the Panchayati Raj Institutions (PRIs) The Village Health and Sanitation Committees Committees (VHSCs) are village vill age level bodies comprised of key stakeholders stakeholders in a village and which serve as a forum for village planning and monitoring. Elected representatives (Members of the PRIs) are generally office bearers of the committee. The main functions of the VHSC and PRI are to ensure that: No section of the village community is excluded from these services.
•
Service providers are available and are able to alert authorities authorities in case of unscheduled unscheduled cancellations of the immunisation day/VHND.
•
Local Local transport arrangements arrangements are available for for pregnant women, especially for those with complications and sick newborn to reach the referral facility, and that in an emergency, this transport is available on a cashless basis with reimbursement later.
•
Nutrition supplement supplement and food security programmes reach the the pregnant pregnant and lactating woman.
•
Focus on the marginalised There are some pregnant women who are too poor or too marginalised to seek even free care. Often they are single women without male support and perhaps with children to look after. This means that their circumstances are straitened by poverty and pregnancy. Lack of child care also limits their access to the facility. Other vulnerable women could belong to recent migrant communities who are not registered in the Sub-Centre and do not speak the local language. They could also belong to a SC or ST group which has historically been excluded from services. The ASHA and the VHSC must bring the knowledge of such gaps to the PRI and the health department. A substantial part of the problem is in recognising the existence of such marginalised sub-groups within the village. Operational Guidelines on
Maternal and Newborn Health
10.2.4. Behaviour Change Communication (BCC) Behaviour Change Communication (BCC) is needed to promote positive health practices for maternal and newborn health, and to discourage harmful practices. A Att the national and state level, this is undertaken through mass media, to build an enabling environment and create societal acceptance for change. Village level interpersonal communication and community mobilisation, are however the major forms of BCC which lead to changed behaviour. Some of the main areas for a BCC strategy to target include:
Reducing the number of adolescent pregnancies, increasing age at marriage, delaying first child birth and increase spacing between pregnancies.
B
Improving nutritional status before and during pregnancy: Ensuring good nutrition during adolescence to improve inter-generational malnutrition, increasing caloric intake, ensuring weight gain of 8- 10 kg, and correcting iron deficiency (anaemia) through proper dietary intake and iron supplementation. Reducing the risk of Human Immunodeficiency Virus (HIV) and HIV related complications: Promoting safe sexual behaviours.
C C
Making informed choices regarding use of family planning methods, including the use of spacing method. Improving infant and young child feeding. Importance of early initiation i nitiation and exclusive exclusive breastfeeding. Information on danger signs in the mother and newborn . Appropriate choices to be made if there are any signs needing referral care.
A BCC strategy would require the following:
Knowledge of the determinants of key behaviours listed above.
Audience segmentation and the choice of appropriate message, medium and communicator to reach mothers, their families and community influencers.
Operational Guidelines on
Measures to monitor and evaluate effectiveness of the BCC components.
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Maternal and Newborn Health
CHAPTER -11
Janani Suraksha Yojana Yojana
Janani Suraksha Suraksha Yojana Yojana is a central scheme scheme that provides cash to the pregnant woman woman from poor and marginalised families, to encourage encourage and empower her to be able to give bir birth th to her child in the safety, safety, comfort and care of an institution. There are costs involved in transport transport,, diet and medical care that poor families have to meet in order to avail of delivery in health facilities. The JSY provides these costs in the form of a cash transfer to such families. The scheme also provides incentives for ASHA to promote institutional delivery and guide and support the pregnant woman to seek appropriate care. The scheme also provides payments for contracting in specialist services in the facilities at Rs. 1500 per case. The JSY also provides a smaller sum as support for those poor women who opt for home delivery for reasons ranging from lack of access, confidence in institutional delivery services or their own cultural beliefs.
11.1. JSY benefit packages at a glance glance 11.1. JSY benefit Place of delivery
Institutional deliveries in
Rural
Package for mothers
Urban
ASHA package
Package for mothers
ASHA package
Low Performing States
1400
600 (200+250+150)
1000
200
High Performing
700
200
600
200
500
Nil
500
Nil
States Home deliveries
Note: ASHA package is applicable only for deliveries in the public sector.
Rs. 1400 given as incentive for institutional delivery
Operational Guidelines on
Maternal and Newborn Health
39
11.2. JSY JSY Financial Financial Package Package for Low Low Performing Performing States 11.2. This includes Assam, Bihar, Chhattisgarh, Jharkhand, Madhya Pradesh, Orissa, Rajasthan, Uttar Pradesh, Uttarakhand, Jammu and Kashmir.
The Beneficiary
All pregnant women who deliver in a government health centre such as a SubCentre, PHC, CHC or FRU or general wards of district or state hospitals. There are no limitations on account of age or parity. There is no need to produce a BPL or SC/ST certificate if the delivery is in a government facility. All pregnant women who deliver in an accredited private institution are eligible. There is no age bar or limitation due to parity. They are required to carry a referral slip from the ASHA, ANM or MO and a JSY
The ASHA is paid Rs. 200 if she promoted institutional delivery in any governmentt facility for both urban and governmen rural families, and ensured ANC care for the woman.
MCH Card.
The Beneficiary Package
Rs. 1400 is paid to the mother in rural areas.
Institutional Delivery Package
Rs. 1000 is paid to the mother in urban areas. This amount is to be disbursed in one single instalment, at the health institutions.
Home Delivery Home Delivery
Rs. 500 is to be paid to any pregnant woman who is: In BPL categ category. ory. Who is over 19 years of age. Only up to two live births. •
• •
A BPL card is not mandatory but certification is required from Gram Pradhan or Ward Member. Payment has to be made at the time of delivery or 7 days before the delivery.
Operational Guidelines on
The ASHA Package
The ASHA receives no incentive if the delivery takes place in a private facility. In rural areas, where ASHA makes transport arrangements and escorts the pregnant woman/family members to the institution she gets paid Rs. 250. In case the arrangements are made directly by the beneficiary the sum of Rs. 250 goes to the beneficiary directly. The sum of Rs. 250 could also be paid directly to the transport service provider. provider. Rs. 150 is paid to the ASHA as transactional costs if ASHA escorts the pregnant woman and stays with her in the hospital. This is also applicable for deliveries in rural areas.
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Maternal and Newborn Health
11.3. JSY Financial Package Package For High Performing Performing States, States, including including UTs UTs and the 11.3. JSY Financial Seven North-Eastern States This includes Andhra Pradesh, Goa, Gujarat, Haryana, Himachal Pradesh, Karnataka, Kerala, Maharashtra, Punjab, Tamil Nadu, West Bengal, Andaman and Nicobar Islands, Chandigarh, Delhi, Dadra and Nagar Haveli, Daman and Diu, Lakshadweep, Puducherry and the north-eastern states of Arunachal Pradesh, Manipur, Meghalaya, Mizoram, Nagaland, Sikkim and Tripura.
The Beneficiary
All pregnant women who are in the BPL category or who are SC and ST and who deliver in a Government health centre-like sub-centre, PHC, CHC or FRU or general wards district hospital or state hospitals or in any accredited private institution. BPL women are eligible only if they have not had more than two live births and are at least 19 years old. BPL certificate and SC/ST certificate are to be produced in public and private facility. For SC/ST women the criteria of parity (not having had more than two live births) is not applicable, and there are no age limitations. The ASHA package
The ASHA is paid Rs. 200 if she promoted institutional delivery in any government facility for both urban and rural families, and ensured ANC care for the woman.
The Beneficiary Package
Rs. 700 is paid to the mother in rural areas.
Institutional Delivery Package
Rs. 600 is paid to the mother in urban areas. This amount is to be disbursed in one single instalment, at the health institutions.
The ASHA receives no incentive if the delivery takes place in a private facility. In the seven North-Eastern Nor th-Eastern States: For transport arrangements made by the ASHA: Rs. 250 For transactional costs if ASHA •
Home Delivery
•
escorts the pregnant the facility: Rs. 150. woman to
Home Delivery
Rs. 500 is to be paid to any pregnant woman who is: In BPL category. Who is o over ver 19 years of age. Only up to two live births in the past. •
• •
A BPL card is not mandatory but certification is required from Gram Pradhan or Ward Member. Payment has to be made at the time of delivery or 7 days before the delivery.
Operational Guidelines on
Maternal and Newborn Health
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Referral Ref erral Units. Uni ts.
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Corners. Functional Description Equipment, Renewable Resources
11. MoHFW. Maternal Health Division. 2004. Guidelines for Operationalising First Referral Units 12. MoHFW. Maternal Health Division. 2004. Guidelines for Operationalising a Primary Health Centre for Providing 24 Hour Delivery and Newborn Care Under RCH-II 13. MoHFW. Maternal Health Division/AIIMS. Life Saving Anaesthetic Skills for Emergency Obstetric Care. Guidelines for Trainers Trainers
Operational Guidelines on
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24. WHO SEARO Mortality Country Fact Sheet, India 2007. World Health Statistics 2007 25. MoHFW, Maternal Health Division, GoI.2004. Infection Management & Environment Plan (IMEP) for Reproductive and Child Health Programme (Phase-II) 26. GoI (2003), Estimate of Maternal Mortality Mortalit y Ratios in India and its States: A Pilot Study, Study, ICMR, New Delhi
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