RMNCAH+N :

Dr. [Link]
Department of Community Medicine
 RMNCAH+N :Package for mothers
1. Early registration of pregnancy
2. Minimum 4 Ante Natal Care + 1 (PMSMA)
3. Anaemia prophylaxis and treatment
4. Calcium supplementation
5. 2 doses of Td/Td Booster
6. Birth preparedness and Complication readiness
7. Institutional delivery/Deliveries by SBA
[Link] to FRU for obstetric emergencies
[Link] based postnatal care
[Link] for birth spacing and limiting
[Link] for MTP
 3 Es

1. Essential obstetric care

2. Emergency obstetric care

3. Early Detection of Complications

 [Link] obstetric care

– Early registration
– Minimum 4 ANC
– 2 doses of Td/TdB
– Anaemia prophylaxis and treatment
– Calcium supplementation
– Institutional delivery/Deliveries by SBA
– Referral to FRU for obstetric emergencies
-Home based postnatal care
 Service delivery points for ANC
ANC services can be availed at
• Village level – at Anganwadi center, during monthly
VHSND
• At health facility – SC, PHC, HWC, CHC, SDH, DH,
and Medical college
• Inform beneficiary that high quality ANC services
provided on fixed day every month in public health
facility under PMSMA
• PMSMA visit is in addition to routine ANC
 Essential obstetric care
• Promotion of institutional deliveries
– 50% of the PHCs and all CHCs made operational as 24
hours delivery centers.
• Skilled attendance at birth
• Policy decisions to permit SBA to use drugs in emergency
situations to reduce maternal mortality
24 hrs. Functioning of PHCs
Availability of Services such as
- 24 Hrs. Delivery services
- New Born care
- Family Planning, Counselling and services
- Availability of RTI, STI services 6
 Antenatal Care
• Effective ANC improves health of mother
• Better chance to deliver a healthy baby
• Regular monitoring helps in early detection of complications
before they become life-threatening emergencies.
• Not possible to predict which woman will develop pregnancy
related complications.
• Hence, every pregnant woman needs special care.
• Every pregnancy is at risk.
• ANC is used as an opportunity to detect and treat existing
problems.
• Services are made available to manage obstetric emergencies
when they occur.
• Preparation of pregnant women and their families for the
eventuality of an emergency
 Priority interventions:

1. Preventive use of folic acid in peri-conception period

2. Pregnancy testing

3. Registration of pregnant mothers

4. Delivery of antenatal care package

5. Tracking of pregnancies

6. Birth preparedness & Complication Readiness

 1. Preventive use of folic acid in peri-conception period

• Use of folic acid in planned pregnancies 5mg/day up to 12 weeks

• During peri -conception phase (3 months before and 3months after
conception)
• Prevention of neural tube defects & other congenital anomalies
• Community-based intervention
• Undertaken by frontline workers and facility-based service providers.
• ASHAs incentivized for delaying birth of first child and for spacing
between births
• Identification of couples who will have a planned pregnancy becomes
easier.
• Pre-pregnancy check-ups.
 2. Pregnancy Testing Kits
• Pregnancy Testing Kits
supplied under brand name
Nishchay to all SCs and
through ASHAs.
• Provision for testing for early
pregnancy should be made
accessible to all adolescent
girls (unmarried and
married)
• Universal access to full
antenatal package should be
focus of service delivery both
at community outreach and
 3. Early registration by ANM
Timing of 1st visit or registration:
• As soon as the pregnancy is suspected.
• Ideally, in 1st trimester before or at 12weeks
• Even if a woman comes late in her pregnancy for
registration, she should be registered, and care given to her
according to the gestational age.
• Registration done at Sub-centre level /VHND
• ANM is assisted by AWW, ASHA, TBA members of Mahila
Mandals, to help update list of pregnant women.
• UID
• Tracking of Pregnancy
 Importance of Early registration
• Assess health status of mother and obtain baseline
information on blood pressure, weight.
• Screen for complications early and manage them
appropriately by referral
• Help mother recall date of her LMP
• Give mother 1st dose of Inj Td (after 12 weeks of pregnancy).
• Help access facilities for an early and safe abortion if she
does not want to continue with pregnancy.
• Be alert to the possibility that abortion might be an attempt
at female foeticide.
• Start on a regular dose of folic acid during the first trimester
Estimation of the number of pregnancies to be
registered annually

• Calculate expected number of live-births in a year in a given

area
• Multiply birth rate (per 1000 population) with population of
the area
• Some pregnancies may not result in a live-birth (abortions
and stillbirths )
• Hence, a correction factor of 10% is required to get total
number of expected pregnancies
• Use local /district /state/national birth rate
Estimation of the number of pregnancies to be
registered annually
• Birth rate = 25/1000 population
• Population under the sub-centre = 5000
• Expected number of live-births = (25 x 5000) / 1000
= 125 births
• Correction factor = 10% of 125 (i.e. [10/100] x 125)
= 13
• Total number of expected pregnancies in a year in that sub-
centre = 125+13 = 138
 Estimation of the number of pregnancies to be
registered annually
• Approximately half the number of pregnancies estimated
should be in record.
• Women receiving ANC from private sector should be
mentioned in antenatal register with a note
• Less than expected number needs tracking with ASHA &
AWW
• Estimation of pregnant woman will also help in calculating
requirement of TT vaccine, IFA, DDK
 Tracking of pregnancies
Mother and Child Tracking system (MCTS)
• Enables service providers to follow up women
• Programme managers can monitor service delivery
• Tracking pregnant women with severe anaemia by ANM and
PHC in charge
• Universal confidential HIV screening should be included as an
integral component.
Maintenance of Records by ANM
• Mother Child Protection Card
• UID, Identifying data, previous health history, main health
events
• Uniformity in Record Keeping
• Details of ANC &PNC
 Antenatal check-up: Number and timing of visits

• 1st visit : As soon as pregnancy is suspected.

Registration of pregnancy and 1st antenatal check-up.
• 2nd visit : 4th - 6th month (26 weeks).
• One USG preferably before 20 weeks (rule out foetal
malformations)
• 3rd visit: 8th month (32 weeks),
• Advisable to visit MO PHC during 3rd visit (PMSMA)
• Avail investigations at PHC/CHC/FRU
• 4th visit: 9th month (36 weeks).
Antenatal check-up: Number and timing of visits
On 4th visit: 9th month (36 weeks).
Warning signs of labour to be explained
• Painful contractions occur at regular interval
• Interval between contractions gradually shortens
• Intensity gradually increases
• Discomfort in back and abdomen
• Presence of bloody mucoid discharge or watery
discharge
• ANM to counsel for regular ANC
 History-taking
• To diagnose pregnancy (1st visit)
• To identify any complications during previous pregnancies
that may have a bearing on the present one
• To identify any medical or obstetric condition(s) that may
complicate the present pregnancy (first and subsequent visits).
History-taking 1st visit
• LMP
• EDD = 9 months + 7 days
• Age
• Occupation
• Duration of marriage
• Birth Order
• Birth Interval
 History-taking 1st & Return visit
Symptoms indicating discomfort
• nausea and vomiting
• heartburn
• constipation
• increased frequency of urination
Symptoms indicating a complication
• Fever
• Vomiting
• Vaginal discharge /leaking of watery fluid P/V
• Vaginal bleeding
• Severe headache /blurring of vision
 History-taking 1st & Return visit

Symptoms indicating a complication

• Difficulty in breathing, Palpitations, easy fatigability
• Generalized swelling of body/puffiness of face
• Severe pain in abdomen
• Reduced urine output/ burning micturition
• Decreased or absent foetal movements
 History of Systemic illness
• Hypertension
• Diabetes
• Heart disease
• Tuberculosis
• Renal disease
• Convulsions (epilepsy)
• Asthma
• Jaundice
• Malaria
• RTI/STI/AIDS
 Past obstetric history
• Number of earlier pregnancies
• Mode, place and outcome of previous deliveries
• No. of living children
• Menstrual history
• Contraceptive history
• Birth weight, age of last child
• History of all abortions
Past obstetric history : Conditions needing referral
• Previous stillbirth(s) or neonatal loss
• > 3 spontaneous abortions
• Prolonged labour /Obstructed labour
• Premature birth(s)
• Birth weight < 2.5 kg or > 4.5 kg
• Congenital anomaly
• PIH / ecclampsia (convulsions )
• Assisted delivery (forceps or vacuum extraction)
• Delivery by Caesarian Section
• Any surgery on reproductive tract
• Treatment for Infertility
• Iso-immunization (Rh negative)
 Family history

• Family history of systemic illness

 Diabetes
 Hypertension
 Tuberculosis

• Thalassemia or repeated blood transfusion

• Twins
• Congenital abnormalities
 Personal History

• History of drug intake or allergies to drugs

• History of intake of habit-forming or harmful substances
• Consumption of tobacco or alcohol
• Treatment for infertility
• Blood Transfusion
• All relevant information is recorded by ANM, in the
Mother Child Protection Card (MCPC)
 General examination
1. Weight- should be taken at each visit.
• Weight taken during 1st visit/registration is baseline
• Normal weight gain 9 - 11 kg during pregnancy.
• After 1st trimester, weight gain 2 kg /month or 0.5
kg /week.
• Weight gain:
• Inadequate diet suspected if weight gain < 2kg per month.
• Refer to AWW for food supplementation
• Low weight gain usually points to IUGR and LBW
• Excessive weight gain > 3 kg/ month should arouse
suspicion of pre-eclampsia/twins / diabetes
 General examination
[Link] pressure- measured at every visit.
• Rule out PIH (2 consecutive readings 4 hours apart BP
>140/90mm Hg)
• If BP > 140/90 mmHg or diastolic > 90 mmHg +
proteinuria = pre eclampsia
• If diastolic BP >110 mmHg, it is a danger sign pointing
towards imminent eclampsia.
• Referred to CHC/FRU immediately .
• A woman with PIH/pre-eclampsia requires hospitalization
at 24X7 PHC/FRU.
 General examination
[Link]: lower conjunctiva, tongue, nails
4. Respiratory rate (RR)
If RR >30 breaths/minute+ pallor indicates severe anaemia
5. Generalized oedema or puffiness of face, tightening of
bangles or rings should arouse suspicion of pre-eclampsia
[Link]
[Link]: 60 -90/min
[Link] Examination: Lump/ inverted or flat nipples, or
crusted or sore nipples
 Abdominal Examination - Fundal height

• 24 weeks : At the level of umbilicus

• 28 weeks : At lower one third of
distance between umbilcus and
xiphisternum
• 32 weeks : At two thirds of distance
between umbilcus and
xiphisternum
• 36 weeks : At xiphisternum
• 40 weeks : Sinks back to the level of
32 weeks but flanks are full
 Abdominal Examination –
1. Fundal height

• If height of uterus is more • If height of uterus is less

than that indicated by than that indicated by
period of amenorrhoea period of amenorrhoea
• wrong date of LMP • wrong date of LMP
• full bladder • IUGR
• multiple pregnancy • missed abortion
• polyhydramnios • intrauterine death
• hydatidiform mole • transverse lie
• pregnancy with a pelvic
tumour
 Abdominal Examination
2. Foetal lie and presentation: longitudinal, transverse or
oblique
If Transverse – Refer to FRU
3. Foetal heart sound (FHS) & rate (> 24 weeks)
• If FHR 120 - 160 beats/ minute, it is normal.
• Both foetal bradycardia and foetal tachycardia indicate
foetal distress –refer to PHC
4. Foetal movements after 20 weeks

• Record all findings in MCPC

 Laboratory investigations
1. Pregnancy Testing Kits (Nishchay)
2. Haemoglobin (Hb) estimation
Anemia -Hb level below 11 g/dl
• Moderate anemia Hb level of 7 to 11 g/dl
• Severe anaemia Hb less than 7 g/dl, refer to FRU
• If mother is anaemic, start her on therapeutic dose of IFA
• Assessment of Gestational age from LMP
• USG in 1st trimester where available
• Foetal anomaly scan at 18 -20 weeks
 Laboratory investigations
1. Thyroid profile
[Link] for Albumin (Dipstick / Boiling)
3 Urine for sugar (Dipstick / Boiling)
[Link] tests for malaria
5. Rapid test for HIV
[Link] grouping
[Link]
[Link] Sugar
[Link]
 Supplementation Interventions
1. Iron and Folic Acid
• Hb level >11 gm/dl
• 60 mg of elemental iron& 500 mcg of folic acid daily
• At least for 6 months during pregnancy.
• Starting after first trimester, at 14–16 weeks of gestation
• Followed by same dose for 6 months in the post-partum period
ASHA to be suitably incentivized for provision IFA supplements to
beneficiary
Hb level between 7- 10 gm/dl
2 IFA tablets (1 in the morning and 1 in the evening) daily for at least 6
months. Hb levels should be reassessed at monthly intervals.
• If on testing, Hb has come up to normal level, discontinue treatment.
• If it does not rise in spite of administration of 2 tablets of IFA daily
and dietary supplementation, refer to next higher health facility for
further management
 Advice for Anemia/ IFA
• Eat plenty of fruits and vegetables (GLV)
• Increase intake of vitamin C rich foods: mango, guava,
orange, lemon to enhance the absorption of iron
• Explain changes noticed after IFA consumption e.g dark
stools, nausea, gastritis
• Advise not to take IFA along with tea, coffee, milk, or
with calcium tablet, as it reduces iron absorption
• Drink more water and add roughage (plenty of green
leafy vegetables) to her diet in case of
• Explain that taking IFA tablets regularly will make the
woman feel better in general and less tired than before.
 Supplementation Interventions
2. Calcium
• Oral calcium tablets 500 mg twice a day (Total 1 gm)
• Preferred formulation is calcium carbonate
• Single dose > 800mg interferes with iron
absorption, so taken in divided doses
• Each tablet contains 500mg elemental calcium and
250 IU Vit D3, to increase absorption of Calcium
• Starting from 14 weeks of pregnancy up to 6
months after delivery
• Should not be taken in empty stomach, causes
gastritis
 Injection Td administration
• Administration of 2 doses of Inj. Td 0.5 ml deep IM in
upper arm
• Prevention of neonatal tetanus
• 1st dose of Td should be given as soon as woman registers
for ANC.
• 2nd dose to be given one month after 1st dose, but at least
one month before EDD
• If woman receives 1st dose after 38 weeks, 2nd dose is given
in postnatal period, after 4 wks
• 1 Booster dose if immunized within 3 years
 Administration of Albendazole

• Tab Albendazole 400mg for all pregnant women in STH

(Strongyloides, Trichuris and Hookworm) endemic areas
• Endemic defined as Prevalence> 20%
• Ideally done under Directly Observed Treatment (DOT)
during ANC visit after 1st trimester
• Women with H/O passing worms, should also receive
treatment
 Birth preparedness
• Assist women, their partners and families to be adequately
prepared for childbirth.
• Understanding on how to respond if complications or
unexpected adverse events occur with PW and/ or baby at
any time during pregnancy, childbirth or the early postnatal
period
• Ensuring skilled delivery care
• Augmenting men’s participation in maternity care
 Birth preparedness (5 Is)
• Inform about essential antenatal and intra natal care
components, signs of labour and danger signs
• Inform expected date of delivery (EDD)
• Itemize essentials required at the time of delivery (e.g.:
money, towel, cloths, transportation etc.)
• Identify place of delivery
• Identify referral facility
 Birth preparedness
• Develop a birth plan
• Should include discussion with mother/family
• Identify a decision maker & support person
• Identification of a skilled provider for birth
• Health facilities where skilled obstetric care is available
• Transport facilities that are now available free of charge in
the public health system.
• JSY & JSSK
• ALL pregnant women must be encouraged to opt for an
institutional delivery
 Signs of labour

• Advise woman to go to 24X7 PHC / CHC or contact SBA if

she has any one of following signs which indicate onset of
labour:
• A bloody, sticky discharge P/V
• Painful abdominal contractions every 20 minutes or less
• Bag of waters has broken, and she has clear fluid coming
out P/V
 Disposable Delivery Kit (DDK):
• All pregnant women should be equipped with DDK
• May be required in case of emergencies
• In case the woman cannot reach health facility in time, and
is forced to deliver at home: 6 “cleans” should maintain.
• Clean plastic sheet ( "clean surface")
• Soap ("clean hands")
• New razor blade ( "clean cord cut")
• Clean pieces of thread ( "clean cord tie")
• Cotton gauge
• Nothing to be applied to cord "clean cord stump “
• “Clean perineum”
 Time to maternal death
COMPLICATION AVERAGE TIME REFERRAL
FROM ONSET TO
DEATH

PPH 2 hours FRU

APH 12 hours FRU
RUPTURED UTERUS 1 day FRU
SEVERE TOXAEMIA 2 days PHC/ FRU
OBSTRUCED LABOUR 3 days FRU
SEPSIS 6 days PHC/ CHC/FRU
SEVERE ANAEMIA 2 hours – 1day FRU
 Three Delays leading to maternal deaths

• Type1 :Delay in deciding to seek care

• Type2 :Delay in reaching appropriate health care
facility
• Type3: Delay in receiving quality care in the
institution
 Complication readiness:
Danger signs : Visit FRU
• Labour lasting longer than 12 hours
• Leaking for more than 12 hours without labor pains
• Failure of placenta to come out within 30 minutes of
delivery
• Preterm labour (labour starting before 9 months)
• Premature or prelabour rupture of membranes
• Continuous severe abdominal pain
• Severe anaemia
• Decreased or no fetal movements
 Complication readiness
Danger signs : Visit FRU
• Any bleeding P/V during pregnancy, and heavy (>500 ml)
vaginal bleeding during and following delivery
• Foul smelling leaking with or without fever
• Severe headache with blurred vision
• Convulsions or loss of consciousness
• Swelling all over body
• Palpitations
• Shortness of breath
• High blood pressure detected in ANC
• Vaginal bleeding in early pregnancy
• Leaking per vaginum before onset of labor
Complication readiness
Danger signs : Visit 24X 7 PHC
• Burning micturition
• High grade fever or any medical illness
• Excessive nausea and vomiting
• High blood pressure detected in ANC
• Fainting and/or pain in abdomen
• Location of the nearest PHC/FRU
• Identification of transportation facilities
• Preparedness for Blood donors
• Janani Suraksha Yojana
• Janani Sishu Suraksha Karyakram
Danger Signs of Pregnancy
 Antenatal Advice -Diet
• Adequate diet is needed to maintain health as a mother,
needs of the growing foetus and successful lactation

• Eat more than her normal diet throughout her pregnancy.

• Extra needs in pregnancy: 350 kcal per day, 23 g protein

• Normal weight gain of 9-11 kg

• One extra meal

• Supplementary nutrition from ICDS centre 600 Kcal , 20 gm

protein daily
 Antenatal Advice -Diet
• Cereals
• Pulses
• Milk and milk products such as curd
• Green leafy vegetables and other vegetables,
• Eggs and meat, including fish and poultry (if non-
vegetarian)
• Nuts (especially groundnuts),
• Jaggery
• Fruits
 Antenatal Advice -Diet
• Locally available foods rich in iron: Green Leafy Vegetables,
groundnuts and jaggery.
• Avoid taking tobacco, tea or coffee, especially within 1 hour
of a meal
• Take foods rich in proteins and vitamin C (e.g. lemon, amla,
guava, oranges, etc.) as both help in absorption of iron.
• Diet should be rich in fibre to avoid constipation
• Drink 10-12 glasses of water, daily
 Antenatal Advice –
• Special groups
• Women with a reduction in the dietary intake below
habitual levels during pregnancy
• Women who have an increased level of physical
activity above the usual levels during pregnancy
• Pregnancy in adolescent girls
• Pregnancy during lactation
• Pregnancy within 2 years of previous delivery
 Antenatal Advice
• Daily intake of IFA and Calcium tablets
• Personal Hygiene
• Avoid Smoking
• Avoid Alcohol
• Avoid Drugs / Radiation
• Rest for 2 hours and Sleep for 8 hours
• Bowels: Avoid constipation
 Antenatal Advice
• Exercise
• Avoid Sexual Intercourse in 1st & 3rd trimester
• Family Planning
• Schedule for next ANC
• Bring MCPC at every visit
• Review Danger signs & Complication readiness
• Long Lasting Insecticidal Net provided in Malaria
endemic areas
 2. Emergency obstetric care
• Strengthen FRUs
• Supply of kits and skilled manpower
• SBA (Skilled Birth Attendants) training
• NGOs involved
• 24-hr Delivery services at PHCs/CHCs:
– Promote institutional deliveries
– Safe deliveries
– Deliveries by trained personnel (SBA) in safe and hygienic
surroundings are encouraged
– Institutional deliveries are encouraged for women having
complications.
– In case of complication, referrals are made to First Referral
Units for Management of obstetric emergencies. 58
 Emergency obstetric care
• Operationalization of FRUs to provide:
– 24 hours delivery services
– Emergency obstetric care
– New born care and emergency care of the sick child
– Full range of family planning services
– Safe abortion services
– Treatment of RTI and STI
– Blood storage facility
– Essential laboratory services
– Referral ( transport ) services
59
 [Link] Detection of Complications

Detected by Self reporting/ ANC

• Bleeding
• Severe anemia
• Convulsions
• Sepsis
• Abortion
• Obstructed Labour
Timely Referral needed
 Service Delivery
• Network of SCs, PHCs, CHCs, FRUs in rural
• Urban health centres and hospitals in urban
• Delivery points: Facilities conducting deliveries
above a minimum benchmark:
L1- minimum 3 normal deliveries / month
L2- minimum 10 normal deliveries / month including
management of complications
L3- minimum 20-50 normal deliveries / month
including C- section
 Service Delivery
• Establishment of dedicated Maternal and child
Health wings in high case load secondary and
tertiary care facilities
• Adequate provision of beds 30/50/100
• Comprehensive units: Antenatal waiting room,
labour room, essential newborn care room, SNCU,
OT, Blood storage units, post natal ward
• Emergency maternal & newborn care
• Quality post natal care for minimum 48 hours
 Referral Transport

• Key issues: Roads, transportation, funds poorly

utilized, Community participation
– Place funds with AWW /ANM [ JSY]
– Develop community mechanisms
– Out source ambulances (Nishchay Jan/ 108)
• Transport should reach patient within 30 minutes
of receiving call
• Transport should reach facility within next 30
minutes
Easy access to ambulance & assistance from AWW
Dr 63
 Role of ASHA
• A village level link worker attached to SC/ANM

• Motivator for ANC, PNC, Institutional Delivery,

Immunization and Family Planning Services

• Provide Escort to beneficiary for above services.

• Adolescents Health Counsellor.

64
 SUMAN- Surakshit Matritva Aashwasan
• Provide assured, dignified, respectful and Quality healthcare
at no cost
• Zero tolerance for denial of services for every woman and
newborn visiting public health facility
• End all preventable maternal and newborn deaths and
morbidities
• Provide, a positive birthing experience.
• "Zero Preventable Maternal and Newborn Deaths and high
quality of maternity care delivered with dignity and
respect"
 Janani Suraksha Yojana (JSY):

• Demand promotion and conditional cash transfer

scheme was launched in April 2005
• Objective is to reduce Maternal, Infant and
Neonatal Mortality.
• Promoting institutional delivery among poor
pregnant women.
 Janani Suraksha Yojana
• 100% centrally sponsored scheme
• Key strategy to achieve reduction of MMR, NMR
• Conditional cash transfer -whether the pregnant
woman chose to deliver in an institution or not.
• Institutional deliveries would help pregnant women
access a team of Skilled Birth Attendant
• It would also improve her access to emergency
obstetric care
• ASHA will be link worker.
 JSY :The package of Incentives
Low performing states High performing states

• Mothers : Rs. 700 in

• Rs.1400 to mothers in rural areas
Institutio rural areas Institutional • Rs.600 in urban areas
nal • Rs.1000 in urban delivery • Rs.600 in rural and
areas package Rs. 400 ( in urban
delivery • Rs. 600 to ASHAs in areas) to ASHAs
package rural,& Rs. 400 in
urban

Home • Rs. 500 to mothers-

Home delivery
package
being BPL , above 19
yrs of ages, ST/ SC
delive • Rs. 500 to mothers-
ry being BPL , above 19
yrs of ages, ST/ SC
packa
ge
 Janani Suraksha Yojana
• 10 LPS- UP, Uttaranchal, Bihar, Jharkhand, MP, Chattisgarh,
Rajasthan, Orissa, J&K, Assam
• LPS – All women delivering in SC/ PHC/FRU/ SD /District
hospitals / Accredited private institutions. All births
• HPS -Only BPL, Aged 19 years and above, SC/ ST, upto 2 live
births
• Subsidizes cost of CS & management of complications to
government institutions where specialists are not in
position– Rs 1500
• Cash assistance for referral transport is over and above
mother’s package – Rs 250 minimum
• ASHA paid only if she accompanies pregnant woman. Paid
after Post natal visits & BCG
 Janani Shishu Suraksha Karyakram
Objective : Reduce Out of Pocket Expenditure and
improve access to health facilities
• Covers entire spectrum of ante natal care, intra
natal care and post natal care for pregnant women
in the institutional setting .
• Ensures free and cashless services to the poor
• Assured and guaranteed services in government
health facilities
• Removed User fee.
 Janani Shishu Suraksha Karyakram
• Entitlement for ALL pregnant women/mothers delivering in public
health institutions, including CS
Free drugs and consumables
Free Essential diagnostic (ANC,INC,PNC)
Free diet during stay Free blood
Free transportation/drop back after48hrs/ in between
institutions
• Free treatment of antenatal and postnatal complications.
• Free entitlements also extended to sick infants
 Janani Shishu Suraksha Karyakram

• Free and no expense delivery including Caesarean

section for all pregnant women delivering in public
health institutions.
• Free drugs, diagnostics, blood and diet
• Free transport from home to institution, between
facilities in case of a referral and drop back home.
• Free treatment for all sick new-born accessing public
health institutions for treatment till one year after
 Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA):

• Hon’ble Prime Minister of India highlighted the aim and

purpose of introduction of the Pradhan Mantri Surakshit
Matritva Abhiyan in the July 31, 2016 episode of Mann Ki Baat
and asked doctors to dedicate 12 days in a year to this initiative.
• A National Portal for PMSMA and a Mobile application have
been developed to facilitate the engagement of doctors from
private/ voluntary sector.
• OBGY specialists / Radiologist/ Physicians working in the private
sector are encouraged to volunteer for the campaign and can
register for the campaign through any of the following
mechanisms:
– Toll Free Number - Doctors can call 18001801104 to register
 Pradhan Mantri Surakshit Matritva Abhiyan
(PMSMA):
Objective
• Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA) was
launched to provide fixed-day assured, comprehensive and
quality antenatal care universally to all pregnant women (in
2nd and 3rd trimester) on the 9th of every month.
• While antenatal care is routinely provided to pregnant women
• Special ANC services are provided by OBGY specialists/
Radiologist/ Physicians at government health facilities under
PMSMA.
• As part of the campaign, a minimum package of antenatal care
services are provided to pregnant women in their 2nd / 3rd
trimesters of at Government health facilities (PHCs/ CHCs, DHs/
urban health facilities etc) in both urban and rural areas
 Pradhan Mantri Surakshit Matritva Abhiyan
(PMSMA):
• Using the principles of a single window system, it is
envisaged that a minimum package of investigations and
medicines such as IFA and calcium supplements etc would
be provided to all pregnant women attending the PMSMA
clinics.

• One of the critical components of the Abhiyan is

identification and follow-up of high risk pregnancies and
red stickers are added on to the Mother and Child
Protection cards of women with high risk pregnancies.
Pradhan Mantri Surakshit Matritva Abhiyan
(PMSMA)
Staff Nurse / ANM
records Height, Weight PW provided a list of
Regn of PW by ANM
,BP Completes MCPC investigations
card

PW takes test report Doctor labels patient

Lab Techn. Takes
&goes to Doctor for as High Risk or Non
Blood& Urine samples
Examination Risk

PW sent for USG and Appropriate

Modification of Report
returns to Doctor with treatment and
if required
report Counselling
 LaQshya: Labour room Quality Improvement
Initiative

• Focused and targeted approach to strengthen key

processes related to the labour rooms and maternity
operation theatres
• Aims at improving quality of care around birth
• Ensuring Respectful Maternity Care.
• Further accelerate decline in MMR
LaQshya: Labour room Quality Improvement
Initiative

• Focused and targeted approach to strengthen key

processes related to the labour rooms and
maternity operation theatres
• Aims at improving quality of care around birth

• Ensuring Respectful Maternity Care.

• Further accelerate decline in MMR

 Overview of LaQshya
• Ministry of Health & Family Welfare, Government of
India launched an ambitious program LaQshya on
11th December 2017

Objectives:
• Reduce maternal and newborn morbidity and mortality
• Improve quality of care during delivery and immediate
post-partum period
• Enhance satisfaction of beneficiaries, positive birthing
experience and provide Respectful Maternity Care
(RMC) to all pregnant women attending public health
 Target Beneficiaries:
• All pregnant woman and newborn delivering in
public health institutions.

• Program will improve quality of care for pregnant

women in labour room, maternity Operation
Theatre and Obstetrics Intensive Care Units (ICUs)
& High Dependency Units (HDUs).
 Following facilities are being taken under LaQshya initiative on
priority:

• All Government Medical College hospitals.

• All District Hospitals & equivalent healthy

facilities.

• All designated FRUs and high case load CHCs with

over 100 deliveries/60 (per month) in hills and
desert areas.
 Strategies (1)

• Reorganizing/aligning LabourRoom & Maternity

Operation Theatre layout as per Standard
Guidelines issued by the Ministry of Health & Family
Welfare, Government of India.

• Ensuring all Government Medical College Hospitals,

District Hospitals have dedicated obstetric HDUs
and Obstetric ICU as per GoI MOHFW Guidelines,
for managing complicated pregnancies that require
life-saving critical care.
 Strategies (2)

• Ensuring strict adherence to clinical protocols for

management and stabilization of the complications
before referral to higher centers.

• Continued mentoring and hand holding support to

improvise skills.
• Regular MDSR, C-section audit and Referral audits &
linkage among lower level facilities.

• Collating best quality practices across States which

 Digital Innovation

• LaQshya Web portal- All LaQshya related data will

be uploaded on the portal for prompt report
generation as well as visualization of dashboard to
monitor progress in key maternal new born
indicators at various levels (facility, District, State
& National)

• Safe delivery App- Job aid as well as training tool

for health workers.
 Certification, Incentives & Branding:

• Quality Improvement in labour room and maternity OT will be

assessed through NQAS (National Quality Assurance Standards).
• Every facility achieving 70% score on NQAS will be certified
as LaQshya certified facility.
• Furthermore, branding of LaQshya certified facilities will be
done as per the NQAS score. Facilities scoring more than 90%,
80% and 70% will be given Platinum, Gold and Silver badge
accordingly.
• Facilities achieving NQAS certification, defined quality indicators
and 80% satisfied beneficiaries will be provided incentive of Rs.
6 lakhs, Rs.3 lakhs and Rs.2 lakhs for Medical College Hospital,
District Hospital and FRUs respectively.
 MOTHERS ABSOLUTE AFFECTION (MAA)

• Objective:
• To promote optimal breastfeeding practices as an
important intervention for child survival and
development.
• To promote, protect and support of breastfeeding
practices through health systems to achieve higher
breastfeeding rate. Reinforce lactation support services at
public health facilities through trained healthcare
providers and through skilled community health workers.
• To incentivize and recognize those health facilities that
show high rates of breastfeeding along with processes in
place for lactation management.
 Key Components:

• Promotion of early initiation of breastfeeding and emphasis on

exclusive breastfeeding till 6 months of age through ASHA
worker and health care provider at health facilities.
• Communication for enhanced awareness and demand
generation through mass media and mid media.
• Implementation of breastfeeding policy for hospitals. Training
and capacity enhancement of nurses at government institutions,
and all ANMs and ASHAs. They will provide information and
counselling support to mothers for breastfeeding;
• Community engagement by ASHAs for breastfeeding promotion,
who will conduct mothers’ meetings. Breastfeeding mothers
requiring more support will be referred to a health facility or the
ANM sub-centre or the Village Health and Nutrition Day (VHND)
organized every month at the village level;
 Key Components:

• Celebration of World Breastfeeding Week (WBW) from 1st to

7th August every year across the country to increase
engagement and create positive momentum for
breastfeeding with diverse stakeholders. Recognition and
team awards will be given to facilities showing good
performance
• Establishment of comprehensive lactation management
centres and lactation management units for ensuring
availability of safe pasteurized donor human milk and
expressed mother’s own breast milk suitable for feeding
sick, preterm and low birth weight babies.
Target Beneficiaries:
• Pregnant and lactating mothers, Families Members and
Key messages to be delivered by ASHA in mother’s
meeting :
• a) Early initiation of breastfeeding; immediately after birth,
preferably within one hour.
• b) Breast-milk alone is the best food and drink for an infant
for the first six months of life. No other food or drink, not
even water, is usually needed during this period. But allow
infant to receive ORS, drops, syrups of vitamins, minerals
and medicines when required for medical reasons.
• c) After 6 months of age, babies should be introduced to
semi-solid, soft food (complementary feeding) but
breastfeeding should continue for up to two years and
beyond, because it is an important source of nutrition,
energy and protection from illness.
 Key messages to be delivered by ASHA in mother’s
meeting :
• d) From the age of 6–8 months a child needs to eat two to
three times per day and thereafter, three to four times per
day starting at 9 months – in addition to breastfeeding.
• Depending on the child’s appetite, one or two nutritious
snacks, such as fruit, home-made energy dense food, may
be needed between meals.
• The baby should be fed small amounts of food that steadily
increase in variety and quantity as he or she grows
 Comprehensive Abortion Care Services
• Provided at public health facilities: 24X7 PHCs/ FRUs
(DHs/ SDHs /CHCs) including Delivery Points.
• Supply of Nischay Pregnancy detection kits to SCs for
early detection of pregnancy .
• Capacity Building of Medical officers in safe MTP services
• ANMs, ASHAs trained to provide confidential counselling
• Promote post-abortion care including contraception.
• District Level Committees for accreditation of facilities
for conducting safe abortion services under MTP Act
 Provision of RTI/STI services:

• To prevent HIV transmission and promote sexual and

reproductive health services in all the FRUs, CHCs and
at 24 X 7 PHCs.
….Thank you…..