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Introduction To Midwifery And Obstetrical
B CHAPTER 1
B Nursing
IN

INTRODUCTION

According to dictionary, “to nurse” means to foster or cherish (“to nurse one's meager talents”), to treat or handle with
adroit care (“to nurse one's nest egg”), to bring up, train or nurture; to clasp or handle carefully or fondly (“to nurse a
memento”); to preserve (“to nurse a drink”). ‘Nurse’ suggests attendance and service; its antonym is ‘neglect’. In the noun
form, a nurse is “a person, especially a woman”, who takes care of sick or infirm; a woman, who has the general care of a
child or children, a woman employed to suckle an infant, or any fostering agency or influence. Thus nurse is a person
formally educated in the care of the sick or infirm, especially registered nurse.

Nurses with highly specialised training would be involved in the high technology tertiary care. At the same time
nurses with broad education will play essential role in directing role and public services particularly conduct safe delivery,
as well as development of women health care programmes that could include family planning, nutrition and healthy child
 birth. Many countries in the west as well as the south-east region have such nurses who are expert in handling midwifery
cases. In India rural scenario where the majority of deliveries are handled by dais where obstetricians are not available
these nursing personnel posted at primary health centre/community health centre. It may turnout with the lifesaving
strategy for woman in labour.

Since midwifery specialists have to be accountable for their actions and decisions taken by them independently,
regulatory bodies like Indian nursing council have to enact such regulation enable the specialist midwives to redirect their
practice to meet the changing health care needs. For example, these midwives should be licensed to undertake essential
life saving emergency measures when necessary. The new category nurses may be named as “Nurse Midwife
Practitioners” who will pave the way for change by establish autonomy are independent practice nursing.

An individual who provides health care also will be called as “Nurse” This statement is not very clarifying. The nurse's
extent of participation in health care varies from simple patient care tasks to the most expert professional techniques
necessary in acute life-threatening situations. The ability of a nurse to function in making self-directed judgements and to
act independently will depend on his or her professional background, motivation and opportunity for professional
development. The roles of nurses constantly change in patterns of demand for health services, and the evolution of
professional relationships among nurses, physicians and other health professionals.

Nursing is not different from other licensed professions, including medicine, licensor is usually sought by the
profession to protect its own interest. For example, the one definition of medical practice states that “practice of
medicine”, means the diagnosis, treatment, prevention, cure, or relieving of human disease, ailment, defect, complaint, or
other physical or mental condition, by attendance, advice, device, diagnostic test or other means, or offering,
understating attempting to do, or holding oneself out as able to do, any of these acts”. Whereas, the practice of the
profession of nursing is defined as diagnosing and treating human responses to actual or potential health problems
through such services—as casefinding, health teaching, health counselling and provision of care supportive to the
restorative of life and well-being; An inclusion of the diagnostic function would authorise the nursing practitioner to make 2
nursing diagnoses, not medical diagnoses. Whereas, the diagnostic function as an intellectual process is central to the
practice of any number of professions including medicine and nursing, the focus in medicine is the nature and degree of
pathology or deviation from normalcy; Within nursing the focus is the “individual response to an actual or potential health
problems and the nursing needs arising from such responses that emphasise on original responses.”

Hence, the practice of nursing means the performance for compensation of professional service requiring
substantial specialised knowledge of the biological, physical, behavioural, psychological, and sociological sciences and
of nursing theory as the basis for assessment diagnosis, planning, intervention and evaluation in the promotion and
maintenance of health; the case finding and management of illness, injury or infirmity; the restoration of optimum

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functions or the achievement of a dignified death. Nursing practice includes, but it is not limited to administration,
teaching, counselling, supervision, delegation and evaluation of practice and execution of the medical regiment including
the administration of medications and treatments prescribed by any person authorised by state law to prescribe. Each
E registered nurse is directly accountable and responsible to the consumer for quality of nursing care rendered.
o
M According to Florence Nightingale ‘a nurse means any person in charge of the personal health of another. Nursing
& ought to assist the reparative process; for nightingale believed that all diseases at some period or other of its course, is
O more or less a reparative process”, and that the symptoms or the sufferings generally considered to be inevitable and
N incidental to the disease are very often not symptoms of the disease at all but of something quite different- of the want
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of fresh air, light, warmth, quiet, cleanliness, punctuality and care in the administration of diet, of each of or all of these.
She further states that the word “Nursing” has been limited to signify little more than the administration of medicines and
IN the application of policies. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper
selection and administration of diet— all at the least expense of vital power to the patient. Accordingly what nursing has
to do is to put the patient in the best condition for nature to act upon him/her.

Virginia Henderson viewed “the unique function of the nurse is to assist the individual, sick or well, in the
performance of those activities contributing to health or its recovery (or to peaceful death) that he would perform
unaided and to do this in such with way as to help him gain independence as rapidly as possible.” Accordingly this unique
function of the nurse is the care of nursing from which all other things spring and which must be protected. Henderson
translates this unique function as “the nurse is temporarily the consciousness of the unconscious, the love of life for the
suicidal, the leg of the amputee, the eyes of the newly blind, a means of locomotion for the infant, knowledge and
confidence for the young mother, the voice for those too weak or withdrawn to speak.”

Today the role of nurses as givers of “primary health care” as those who diagnose and treat when a doctor is
unavailable, even as the nurse midwife function in the absence of an obstetrician/nurse may be general care providers of
primary care. Obstetrical nurses or midwives have been universally recognised worldwide as the providers of primary
care for mothers and newborns. They diagnose and treat as well as “care”. Nursing roles have expanded because the
talent is there and because there is a need, whether the need is for people to manage the care of the chronically mentally
 ill, manage the care of rape victims, including testifying in court or devise and manage care for patients awaiting heart
transplants. When nurses do it, it is nursing.

TRENDS IN MIDWIFERY AND OBSTETRICAL NURSING

Owing to the fact that childbirth was commonly regarded in India as a time of impurity, it followed that only those whose
caste was low could attend a woman of such time. From time immemorial, the presiding genius at the birth of children
was the hereditary dai (Midwife). Such women were quite untrained and that only knowledge consisted in what was
passed on by their predecessors or learned by experience. They had no idea of the mechanism of Labour or of the
danger of sepsis, and in any difficulty, their remedy was force, often with disastrous consequences. 3

When medically qualified women started their practice in India, they realised the importance of establishing some
system of training of these traditional midwives (dais). This was by no means an easy task, because the dais themselves
for the most part, opposed any scheme for training, and refused to attend classes when arranged. They were suspicious,
and there was some trap in the scheme to out them from their means of livelihood. Another factor which militated
against their coming forward for training was that their patients also did not realise the need for a higher standard of skill
in their attendants at childbirth and were content to continue in the way of their forbears. One of the first attempts to train
these women was made by Miss Hewlett, a missionary in America, in 1886. She persuaded them to attend her classes by
paying them a fee for each attendance, the funds being supplied by the Municipality of Amritsar. After a certain length of
training, the dais were given an examination, and those who were successful in the examination received a certificate. A
hold over them was maintained by requiring them to report every case as soon as the confinement was over, upon which
Miss Hewlett or her assistant then visited the case. If all was well, the dai (Traditional midwife) was given a rupee, and
although the dais had no enthusiasm for reporting the case, they were glad to win the rupee, and the system worked well.
Similar attempts were made in a few other places by medical missionaries and were usually attended with some
success.

In Madras (now Chennai) Tamil Nadu State, the object consistently aimed at, has been to oust the indigenous dais by
means of training a superior class midwife.

‘Midwife’ means “with woman” or in France, “wise woman.” Throughout the ages, women have depended upon a
skilled person, usually another woman, to be with them during childbirth. Now-a-days, in response to women seeking
alternatives to physician-hospital services, there has been rebirth of the ‘lay midwife (traditional midwife), the empirically
trained midwife. She is usually a mother who learned by apprenticing to another who lay midwife and is responding
primarily to women who seek to give birth at home. Unlike “granny midwife” of old, today's lay midwife is usually middle
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class, well educated, articulate, and wellpaid for her services. As she gained experience and confidence, she questions
the need for prerequisite of nursing by these new midwives. They allege that nursing education promulgates the medical
model of pregnancy as an illness and birth as a medical event. They further allege that nursing education teaches
E subservience to medical doctrine even when the doctrine is not supported by scientific research.
o
M The views of individual nurse midwives are divided and the profession has avoided taking a stand on whether it is
& essential to be a nurse before becoming a midwife. However, most agree that if not a prerequisite, the inclusion of
O aspects of nursing education are desirable. The expanded opportunities for practice are creating an increased demand to
N educate nurse-midwives. It is clear that professionals trained exclusively in medical institutions experience discomfort
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practising in the maternity homes (birth centres) setting. Therefore, if nurse-midwives are to be the primary care
providers for childbearing families and birth centres a place for practice of midwifery, a new approach to the education
IN and training of nurse-midwife is called for. Maybe, realizing these views, in India, Midwifery course replaced by two years
Auxiliary-Nurse Midwifery course (Now Female Health Worker Training course) and sick nurse training replaced by three
and half years General Nursing and Midwifery course. In addition, four years BSc Nursing course curricula included the
major components of Midwifery, Obstetrics and Gynaecological nursing. And there is such speciality in Master degree in
Nursing and Doctoral degree in Nursing.

Now nurse-midwives are recognised as the experts and lead caregivers in normal childbirth. Hence, the nurse-
midwife is a person who, having been regularly admitted to a nursing/midwifery education, duly recognised in the state,
or country, in which it is located, has successfully completed the prescribed course of studies in nursing and midwifery
and has acquired the requisite qualifications to be registered and/or legally licensed to practise nursing and midwifery.

The nurse-midwife must be able to give the necessary supervision, care and advice to women during pregnancy,
labour and the post-partum period, to conduct deliveries, on her own responsibility and to take care for the newborn and
the infant. This care included preventable measures, the detection of abnormal conditions in mother and child, the
procurement of medical assistance and the execution of emergency measured in the absence of medical help. The 4
nurse-midwife has an important task in health counselling and education, not only for the woman, but also within the
family and the community. The work should involve antenatal education and preparation for parenthood, and extends to
 certain areas of gynaecology, family planning and childcare. She may practise in hospitals, clinics, health units,
domiciliary conditions or in any other service.

The activities of nurse-midwives includes:

To provide sound family planning information and advice.

To diagnose pregnancies and monitor normal pregnancies to carry out examination necessary for the monitoring of
the development of normal pregnancies.
To prescribe or advise on the examinations necessary for the earliest possible diagnosis of pregnancies at risk.
To provide programme of parenthood preparation and complete preparations for childbirth including advise on hygiene
and nutrition.
To care for and assist the mother during labour and to monitor the condition of the foetus in utero by the appropriate
clinical and technical means.
To conduct spontaneous deliveries including where required an episiotomy and in urgent cases of breech delivery.
To recognise the warning signs of abnormality in the mother or infant which necessitate referral to a qualified medical
doctor and to assist the latter where appropriate; to take the necessary emergency measures the medical doctor's
absence, in particular the manual removal of placenta, possibly followed by manual examination of the uterus.
To examine and care for the newborn infant, to take all initiatives, which are necessary in case of need and to carry out
where necessary immediate resuscitation.
To care for and monitor progress of the mother in the postnatal period and to give all necessary advice to the mother
on infant care to enable her to ensure the optimum progress of the newborn infant.
To carry out the treatment prescribed by a medically qualified doctor.
To maintain necessary records.

Today nurses serve in hospital, railway service, military service, community health centres and clinics and patient
homes, maternity and nursing homes and some even hang out their own shingle in private practice, for which nurses
have studied and have and update their knowledge and skill in specialized areas which includes and child health.
Maternal and child health also includes subspecialities like obstetrics and gynaecological nursing, neonatal nursing,
paediatric nursing, etc.

New nurses are attracted to and stay in positions that enable them to practise in their desired nursing speciality.
About half of them cited the ability to practise their speciality as the primary source of their satisfaction, and almost one-
third cited it as the reason for selecting their current position. Most nurses work in hospital settings. Hospitals vary

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widely in size, services offered, and geographic location. In general, nurses in hospital, work with patients who have
medical or surgical conditions, with children, with women and their newborn, with cancer patient, with people who have
had severe traumas (injuries) or burns in operating rooms or emergency rooms, and in many other capacities. In addition
E to direct patient care roles, nurses in hospitals serve as educators, managers, and administrators, who teach or supervise
o others and establish the directions of nursing hospitalwise.
M
& Obstetrical nursing is one of the specialised area in nursing which focuses on women and their infants and families
O during the child bearing cycle. It deals with women's health nursing, and reproductive health nursing. Brief description of
N these terminology are as follows:
B
B Obstetrical nursing focuses on the case of child-bearing and their families through all stages of pregnancy and
childbirth and during first-six weeks after birth. Throughout the prenatal period, nurses and nurse-midwives provide care
IN
for women in clinics, and health centres and teach classes to help families to prepare for childbirth. They also care for
childbearing families during labour and birth in hospitals, birth centres (maternity homes) and less frequently the home.
Nurses with special training may provide intensive care for high-risk neonates in special care units and high-risk mothers
in antepartum units, in critical care obstetric units, or at home. Maternity nurses teach about pregnancy, the process of
labour, birth and recovery, and parenting skills. Investment in health promotion during child bearing can make a 5
significant differences in the health of women and their infants.

Women's health nursing focuses on the physical, psychologic and social needs of women throughout their lives. The
term “women's health” emphasises the overall experience of women diseases, child bearing functions, and general,
physical and psychologic well-being. Women's health nurses specialise in and investigate conditions unique to women
(such as reproductive malignancies and menopause) and socio-cultural and occupational factors that may be related to
women's health problems (such as poverty, lower wages, rape, incest, sexual harassment and family violence).

Nurses caring for women have helped make the health care system more responsive to women's needs. The
changing health care delivery system offers opportunities for nurses to alter nursing practice and improve the way of
care, is delivered through managed care, integrated delivery systems and redefined roles. Nurses have been critically
 important in developing strategies to improve the well-being of women and their infants. Still, there are serious problems
related to the health and health care of mothers and infant exist. Access to pre-pregnancy and pregnancy-related care for
all women and the lack of reproductive health services for adolescents are major concerns. Nurses can influence
national health policy by actively participating in the education of the public and states and union governments.

Reproductive Health and Maternity form an important aspect of women's health and are considered and element of
primary health care, especially as they relate to maternal-child health. Also, women usually enter the health care system
for reporductive care. In a number of countries maternal mortality rates remain at alarmingly high levels, as does the low
nutritional status of women throughout their reproductive cycles. It has been estimated that there are at least half a
million maternal deaths in the world per year that are preventable. This maternal mortality is not evenly distributed in
different parts of the world, for example, women in Bangladesh face a risk of dying 400 times greater than that of women
in Scandinavia and 50 times greater than that of women in Portugal. In India, 1.1% of all deaths in the country in 1991
were due to maternal causes (SRS). At a crude death rate of 9.8 per 1000 an estimated 8,29,3770 deaths occurred of
which 91,231 were related to pregnancy and childbirth. Based on these numbers the estimated maternal mortality rate
would be around 62.9 per 100,000 women in the reproductive age group of 15 to 44 years or a maternal mortality ratio of
3.4 per 1000 deliveries.

In India, more than 2 crore 70 lakhs pregnancies take place every year. Of these more than half are attended by
untrained birth attendants or relatives. To improve the quality of ante-natal, natal and post-natal care in domiciliary
deliveries, it is important that every health worker including nurses builds up a rapport with the Traditional Birth
Attendants (TBAs) leading to a community based midwifery service in close conjunctions with the TBAs, Anganawadi
workers and the community. It is estimated that of all pregnancies 15% will develop some complications requiring
treatment at a hospital, out of which 5% may need an operation to deliver the child and to save mother. In such a
situation, it is essential that all the maternal service at the community level are organised in a way that every pregnant
woman received adequate care and identification of complications is done during ante-natal, natal and post-natal period.
Appropriate referral of complicated cases is most crucial to save the mother and newborn from disease or death related
to pregnancy.

Maternal and child health care which is now also being described as “Reproductive and Child Health” is a very
important component of the family welfare programme in India. Reproductive and Child Health (RCH) can be defined as a
state in which “people have the ability to reproduce and regulate their fertility; women are able to go through the
pregnancy and child birth safely, the outcome of pregnancy is successful in terms of maternal and infant survival and
well-being, and couples are able to have sexual relations free of the fear of pregnancy and contracting disease. This
means that every couple should be able to have child when they want and that the pregnancy, the mother and the child
are safe and well, and contraceptives by choice are available to prevent pregnancy and of contracting disease.” The need
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for and underlying principles of reproductive health as an approach to solve the population issues were duly highlighted
and agreed upon by participating countries during the International conference on “Population and Development” held in
Cairo in 1994. In agreement to this decision, the Govt of India has formally launched the Reproductive and Child Health 6
E (RCH) programme on October 15, 1997.
o
M RCH Programme has envisaged a major shift in certain components, approach and emphasis of the already existing
& Family Welfare Programme in India. Major focus in this programme is delivery of need based client centred, good quality,
O comprehensive reproductive and child health services to all the beneficiaries in an integrated manner. In India, the RCH
N services are to be delivered through the existing primary health care infrastructure with necessary referral and
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supervisory support from the secondary and teritary level institutions. Capacity building among the personnel involved in
the delivery of RCH services through in-service training, is considered as an essential prerequisite for the successful
IN implementation of the programme. Strengthening of task performance skills for delivery of RCH service is particularly
felt as required. Accordingly integrated skill development training of primary health care personnel being organised, in
which they are trained in these components in an integrated manner throughout the country. The staff nurses placed at
primary health centres and community health centres are also covered under this integrated skill training.

As already stated, reproductive health and maternity form an important aspect of women's health and is considered
an element of Primary Health Care, especially as they relate to Maternal Child Health. Women often enter the health care
system because of reproductive issues or problems.

HISTORICAL PERSPECTIVES AND CURRENT TRENDS IN INDIA

All health activities in the community are concerned with the wellbeing of all people irrespective of age, sex, race, or other
characteristics. However, two groups, i.e., women in the reproductive age group and children especially underfives merit
special attention. In India, women of the childbearing age (15-44 years) constitute 19 per cent, and children under 15
years of age about 40 per cent of the total population. Together, they constitute nearly 59 percent of the total population.
By virtue of their number, mothers and children are the major consumers of health services. These groups are subjected
 to marked physical and physiological stress, which, if not cared for, may cause serious deviation from normal health.
Mother and children are not only constitute a large group, but they are also a “vulnerable” or “special risk group.” The risk
is connected within the case of infants and children, since they are exposed to unusual risks of widespread infection,
poor nutrition, and hazardous delivery, which may cause death or impairment of health.

According to the available sources, 50 per cent of all deaths in the developing world are occurring among people
over 70 years, the same proportion of death occurring among children during the first-five years of life in the developing
world. Global observation shows that in developed regions maternal mortality ratio is in averages at 30 per 100,000 live
births; in developing regions the figure is 480 for the same number of live births.

The problems affecting the health of the mother and child are multifactorial. Despite current efforts, the health of the
mother and child still constitute one of the most serious health problems affecting the community, particularly in the
developing countries including India.

The protection of the health of the expectant mother and her children is of prime importance for building of a sound
and healthy nation.

The maternal and child welfare movement in India started with attempts to train indegenous “dai” (Traditional birth
attendant, TBA) by Miss Hewlett of the Church of England Zenana Mission in India 1866. Wives of officials returning from
foreign countries started some services through voluntary societies in big towns, such as holding of mothers, classes
and training of indigenous dais. Lady Chelmsford was much interested in this work and she established the “All India
League of Maternity and Child Welfare” in 1919 and opened Health Schools for training of health visitors in many big
towns. Later on the League became incorporated with the Redcross Society. Training of Midwives, Assistant Midwives
and Dais was also conducted at some places. Till 1953, the MCH services in the districts were patchy and were rendered
through Maternity homes and trained Midwives. The latter were under the control of the Civil Surgeons and their services
mostly curative and institutional. From 1955 onwards, MCH services are rendered through MCH centres or maternity
homes run by local bodies.

Today's health care environment is distinctively different from that of the past. The increasing emphasis on health 7
care reform, cost effective treatment, shorter or eliminated hospital stays, and improved quality of care has changed
where is health care delivered, how is it delivered, and by whom does it change in health care delivery in the last decade
have resulted in significant alterations in the traditional approaches to career pathways for nurses. The expanded
opportunities for practice are creating an increased demand to educate nurse-midwives. Keeping in view of the above
changes in India, long back, we have introduced Midwifery, Obstetrics, and Gynaecological components in the curricula

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of ANM, LHV, GNM, BSc and MSc. Nursing courses longback to meet the future changing health needs of the community
accordingly. So, the nursing practice must change in response to health care system changes, and consumer demands.

E In any nation, mother and children constitute a priority group which consists about 70 per cent population, in India,
o women of the child bearing age (15-44 years) constitute 19 per cent and children under 15 years of age about 40 per cent
M of the total population. Together they constitute nearly 59 per cent of the total population. By virtue of their numbers,
& mothers and children are the major consumers of health services. And they are also a vulnerable or special risk group.
O The risk is connected with child bearing in the case of women, and growth and development, and survival in the case of
N infants and children. Whereas, 50 per cent of all death in the developed world are occurring among people over 70 and
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the same proportion of death occurring among children during the first-five years of life in the developing world. Much of
the sickness and death among mothers and children is largely preventable.
IN
In practice, mother and child must be considered as one unit. It is because:

During ante-natal period, the foetus on the part of the mother, the period is about 280 days. During this period, the
foetus obtains all the building material and oxygen from the mother's blood.
Child health is closely related to maternal health. A healthy mother brings forth a healthy baby; there is a less chance
for a premature birth, still birth, or abortion.
Certain diseases and conditions of the mother during pregnancy (e.g., Syphilis, German measles, drug intake) are likely
to have their effects upon the foetus.
After birth, the child is dependent upon the mother. At least upto the age of 6 to 9 months, the child is completely
dependent on the mother for feeding. The mental and social development of the child is also dependent upon the
mother. If mother dies, the child's growth and development are affected (Maternal deprivation syndrome).
In the care cycle of women, there are few occasions when service to the child is not simultaneously called for.
The mother is also the first teacher of the child.

It is for these reasons, the mother and child are treated as one unit. Maternal and child health services were first

 organised in India in 1921, by a committee of “The Lady Chelmsford League” which collected funds for child welfare and
established demonstration services on an All India basis. In 1931, Indian Red Cross Society started maternity centres in
different parts of the country through its “Maternal and Child Welfare Bureau”. In 1946, the Health Survey and
Development Committee headed by Sir Joseph Bhore, emphasised the need for maternal and child welfare services and
recommended that priority should be given for MCH services in the National Health Service.

The constitution of India envisages the establishment of new social order based on equality, justice, and dignity of
the individual. Among others, it directs the state to record improvement in the public health in one of the primary duties
and aims at securing the health and strength of the workers, men and women, and the tender age of children are not
abused and that citizens are not forced by economic necessities to enter avocations unsuited to their age or strength
and that children are given opportunities and facilities to develop in a healthy manner in conditions of freedom and their
childhood and youth are protected against exploitation and against moral and material abandonment (Article 39). And
the state shall regard the raising of the level of nutrition and standard of living of its people and improvement of public
health as among its primary duties (Article 47).

National Policy for Children (1977): It shall be the policy of the State to provide adequate services to children, both
before and after birth and through the period of growth to ensure their full physical, mental and social development. The
state shall progressively increase the scope of such services so that within a reasonable time all children in the country 8
enjoy optimum conditions for their balanced growth. It has been also indicated priority in programme formulations. In
formulating programmes in different sectors, priority shall be given to programmes relating to:

1. Preventive and promotive aspects of child health.

2. Nutrition for infants and children in the preschool age.
3. Maintenance education and training of orphans and destitute children.
4. Creches and other facilities for the care of children of working and ailing mothers.
5. Care, education, training and rehabilitation of handicapped children.

The policy on Family Welfare Programme (1977) also stated that “it is of utmost importance that adequate, ante-
natal and post-natal care is made available to pregnant mothers. To this end a comprehensive scheme of training of
indigenous midwives (Dais) will be implemented. Under it, maternity services will be made available to all mothers who
may need them. The programme of immunising children against common diseases, such as whooping cough, diphtheria,
and tetanus will be expanded further. We expect that the State Government will give necessary cooperation and
assistance in this direction since health is a state subject.

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And there is direct correlation between the illiteracy and fertility, and between infant and maternal mortality, and the
age at marriage is well established by demographic studies. While on the other hand, government will pursue its policy to
the improvements of women's education level, both through formal and nonformal channels according high priority. It will
E also bring legislation for raising the minimum age of marriage for girls to 18 and for boys to 21 years.” This has been
o done through Child Marriage Restraint Act 1978.
M
& The joint conference of Central Councils of Health and Central Family Welfare Council at its meeting held in April
O 1979, among other things have resolved that” as a part of the package of family welfare, we have to mount gigantic
N efforts to radically reduce infant and child mortality to at least 50 per cent of the present levels in the shortest possible
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time. This calls for not only much more expanded immunisation and prophylaxis against nutritional deficiency diseases
but also efforts to combat major causes of such mortality namely diarrhoeal and respiratory diseases and malnutrition.
IN
Alma-Ata Declaration on Primary Health Care (1978) stated “that primary health care includes at least education
concerning prevailing health problems and the methods of prevailing and controlling them; promotion of food supply and
proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family
planning; immunisation against major infectious diseases; prevention and control of total endemic diseases; appropriate
treatment of common diseases and injury and provision of essential drugs.”

In the month of 1980, the Government of India signed the Charter for Health Development proposed by the World
Health Organization. The preamble of the Charter reads.

“A nation's greatest asset is people, the more so, when they are endowed with the highest obtainable standard of
health, which promotes creativeness, dynamism, determination, productivity, and self confidence to move ahead.” Health
is a basic requirement not only for fulfillment of human aspirations but also for the enjoyment of all mankind of a better
quality of life. It is also indispensable for a balanced development of the individual within the family and as part of the
community and the nation. There is an urgent need to mobilise and make effective use of all the human resources
available in our countries if we are to make rapid economic and social progress. Therefore to meet this need, we the
Government, represented by the undersigned, have come together to draw up an effective plan for improving the status
 of health of our people. Article 6 spells out the specific objectives…(6) The reduction of mortality and morbidity among
infants, and children, the improvement of the health of women, especially mothers, and the regulation of fertility, so as to
achieve better health and implement national population policy.

According to World Health Organization, the MCH Services should ensure that:

“Every child, wherever possible, lives and grows up in a family unit, with love and security, in healthy surroundings,
receives adequate nourishment, health supervision and efficient medical attention, and is taught the elements of healthy
living.”

“Every expectant and nursing mother maintaining good health, learns the art of child care, has a normal delivery, and 9
bears healthy children.” Maternity care in the narrower sense, consist in the care of the pregnant women, safe delivery,
post-natal care, care of her newly born infant, and the maintenance of lactation. In the wider sense, it begins much earlier
in the measures aimed to promote the health and well being of the young who are potential parents, and to help them to
develop the right approach to family life and to the place of family in the community. It should also include guidance in
parent-craft and in problems associated with infertility and family planning.

Under the constitution of India, the subject of health facilities, including their planning, establishment and
administration, falls under the purview of respective governments of States of the Union. However, Government of India
has from time to time introduced National Health Programme, which are either centrally sponsored, i.e., part of expense
is met by the Central Government, or wholly funded by the centre. Ministry of Health, Government of India, with the help
of Central Councils of Health and Family Welfare has taken several initiatives in launching programmes, aimed at
controlling or eradicating diseases which cause considerable morbidity and mortality in India. New programmes are
being added and existing ones modified, in response to changing epidemiology of disease, host or parasites.

NATIONAL PROGRAMME RELATED TO MOTHER AND CHILD HEALTH

The important National Health Programmes are as follows:

1. Maternal and Child Health Programme (MCH)

2. Integrated Child Development Service Scheme (ICDS)
3. Child Survival and Safe Motherhood Programme (CSSM)
4. Reproductive and Child Health Programme (RCH).

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NATIONAL PROGRAMMES RELATED TO COMMUNICABLE DISEASES

E
o
M DISEASE ERADICATION PROGRAMMES
&
O 1. National Malaria Eradication Programme
N
2. National Leprosy Eradication Programme
B
B 3. National Yaws Eradication Programme
4. National Polio Eradication Programme
IN
5. National Small Pox Eradication Programme (succeeded)
6. National Guinea Worm Eradication Programme (succeeded).

DISEASE CONTROL PROGRAMMES

7. National Filaria Control Programme

8. National Tuberculosis Control Programme
9. National AIDS Control Programme
10. National STD Control Programme
11. National Diarrhoeal Disease Control Programme
12. National ARI Control Programme
13. National Cholera Control Programme
14. National Trachoma Control Programme

15. National Anti Malaria Programme.

NATIONAL PROGRAMMES RELATED TO CONTROL OF NUTRITIONAL DEFICIENCIES AND DISORDERS

1. Vitamin A Prophylaxis Programme

2. Nutritional Anaemia Control Programme
3. National Iodine Deficiency Disorders Control Programme
4. Special Nutrition Programme
5. Balawadi Nutrition Programme
6. Integrated Child Development Scheme (ICDS)
7. School Mid-day Meal Programme.

NATIONAL PROGRAMMES RELATED TO CONTROL OF NONCOMMUNICABLE DISEASES

1. National School Health Programme

2. National Cancer Control Programme
3. National Mental Health Programme
4. National Diabetes Control Programme
5. National Drug-de-addiction Programme
6. National Programme for Control of Blindness.

MATERNAL AND CHILD HEALTH PROGRAMMES

Women of the reproductive age groups (15-44 years) and children (male and female below 15 years of age) constitute
almost 60 per cent of the population. Mothers and children are considered as a special group for the following reasons:

1. By virtue of their numbers, mothers and children are major consumers of health service. They comprise of
approximately two-thirds of the population in the developing countries. In India, women in the child-bearing age (15 to 10

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less than 45 years) constitute 22.8 per cent and children under 15 years of age 37.1 per cent of the total population.
Thus together they constitute nearly 60 per cent of the total population.
2. These groups are subjected to marked physical and physiological stress, which if not cared for, may cause serious
E deviation from normal health.
o
M 3. They are exposed to unusual risks of widespread infection, poor nutrition, and hazardous delivery, which may cause
& death or impairment of health. The high occurrence of morbidity among women and children is reflected in a seven
O village study (Trackrov PL, L.Kapoor J.D 1990 NIHFW).
N
B The protection of the health of the expectant mother and her children is of prime importance for building of a sound
B and healthy nation.

IN Maternal and Child Health (MCH) refers to preventive and curative health care activities for mothers and children.
The objectives of MCH are:

To reduce maternal, infant and childhood mortality and morbidity.

To promote reproductive health.
To promote physical and psychological development of children and adolescent.

The mother and child should be considered and treated as one unit for providing health services because of the
following reasons:

During antenatal period the foetus is part of the mother, The period of development of the foetus is about 40 weeks.
During this period it obtains all necessary supplies to nutrients and oxygen from the mother's blood.
The health of the child is intricately linked to the mother's health.
Certain diseases inflicting the mother during pregnancy can have that deleterious effect on the health of the foetus.
Even after birth, the child is dependent for its feeding upon the mother, at least in the first year of life.
During the first few years of life, the child usually accompanies the mother during her visits to the health facilities and

 there are few occasions when services to the mothers and children are not simultaneously called for.
The mental and social development of the child is also dependent on the mother. The mother is the earliest teacher of
the child. The death of the mother causes a maternal deprivation syndrome in the child.

The policy guidelines for implementation of MCH programme are:

1. Effective use should be made of existing resources and infrastructures available in the community.
2. The services should be delivered as close to the homes of beneficieries as possible.
3. Services for mothers and children should be delivered, in an integrated manner.
4. Child survival programmes should serve as a sugar-coating for delivery of the family planning programmes which in
general are not popular.
5. Voluntary agencies working in the area should be involved in providing MCH services.

World Health Organization (WHO) in 1989 gave call for child survival and safe motherhood (CSSM) programme
which was implemented by the Govt. of India. This programme was initiated in 1992. It is yet another exercise of
renaming old programmes which have existed for several years and repacking them with a new name. The different
components of the CSSM Programme are: advice on breastfeeding, care of the newborn infant, resuscitation of the
neonate, care of low birth weight infant and also services to pregnant women. The CSSM Programme with an integrated
package of intervention for improving the health status of women and children and reducing the maternal infant and
child mortality rates. The services under this programme provided to pregnant women, infants and children under 5 years
of age include:

PREGNANT WOMEN

Essential care for all:

Register by 12 to 16 weeks.
Antenatal check up at least 3 times.
Immunisation with TT.
Give IFA-large tablet to all (1 tablet a day for 100 days).
Treat those with clinical anaemia (2 tablets a day for 100 days).

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Deworm with mebendazole (during 2nd/3rd trimesters in a case where prevalence rates of hookworm infestation
are high.
Care and clean delivery services.
E
Prepare the woman for exclusive breast feeding and timely weaning.
o
M Postnatal care, including advice and services for limiting and spacing births.
& Early detection of complications:
O 11
Clinical examination to detect anaemia.
N
B Bleeding indicating APH or PPH.
B Weight gain of more than 3 kg in a month or systolic BP of 140 mmHg or more diastolic BP of 90 mmHg or more.

IN Fever 39°C and above after delivery or after abortion.

Prolonged or obstructed labour (labour pain for more than 12 hours).

Emergency care for those who need it:

Early identfication of obstretric emergencies.
Provide initial management and refer to identified referral unity.
Use fastest availiable mode of transport.

Women in the reproductive age group.

Counselling on:
Optimal timing and spacing of birth.
Small family norms.
Use and choice of contraceptives.

Information on availability of:

MTP services.
IUD and sterilization services.

The package of services under CSSM Programme are:

FOR THE MOTHERS

Immunisation.
Prevention and treatment of anaemia.
Antenatal care and early identification of maternal complications.
Deliveries by trained personnel.
Promotion of Institutional deliveries.
Management of obstetric emergencies.
Birth spacing.

FOR CHILDREN

Essential newborn care.

Immunisation.
Appropriate management of diarrhoea.
Appropriate management of ARI
Vitamin A prophylaxis.
Treatment of anaemia.

INFANTS

Newborn care
Birth weight for all new borns.
Resuscitation of asphyxiated babies.
Care of low birth weight babies.

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Prevention of hypothermia.
Exclusive breastfeeding within 1 hour of delivery.
Referral of newborns who show signs of illness.
E
o Advice to mother on essential newborn care, prevention of hypothermia, and infections, nutrition (breastfeeding and
M weaning), immunisation, Vitamin ‘A’ prophylaxis and early signs when to seek help.
& Immunisation
O
N — BCG 1 dose at birth.
B
B — DPT 3 doses beginning 6 weeks at monthly intervals

IN — Polio ‘0’ dose at birth for all institutional deliveries 3 doses beginning 6 weeks at monthly interval.

— Measles 1 dose at completion of 9 months of age.

— Vitamin A First dose (100,000 IU) with measles vaccination.

CHILDREN (1-3 YEARS)

Immunisation.
DPT/OPV booster dose at 16 to 18 months.
Vitamin A Second dose (200,000 IU) at 16 to 18 months along with DPT/OPV booster.
Third dose to 5th dose (200,000 IU each) at 6 months interval

CHILDREN (1-6 YEARS)


Prevention of anaemia.
IFA-small tablets of child has clinical signs of anaemia.
Stool examination for hookworm infestations (where facilities are available).
Deworm with mebendazole (during 2nd/3rd trimester) in areas where prevalence rates of hook-worm infestation are
high.

Prevention of deaths due to diarrhoeal diseases.

Correct care management for all cases of diarrhoea.
Advice mothers.
To give increased volume of fluids (ORS or HAF (Home Available fluids) as soon as diarrhoea starts).
How to prepare ORS solution.
Continue feeding the normal diet.
To recognise signs when to seek help.

Prevention of deaths due to pneumonia.

Correct case management for all cases of acute respiratory infections.
Early initiation of cotrimoxazole to children with signs of pneumonia.
Referral of children with severe pneumonia or very severe illness. 12

The rapidly growing population had been a major concern for health planners and administrators in India since
independence. The result was the launching of the National Family Planning Programme by the Government of India in
1952, which later became Family Welfare Programme. India is the first country to have taken up the family planning
programme at the national level. Poor health status of women and children in terms of high mortality and morbidity was
also a other priority in India. Health facilities like hospitals and health centres were established for providing MCH care
through ante-natal, intra-natal and post-natal services.

In addition, a number of special programmes and schemes like immunisation against vaccine preventable diseases,
nutritional intervention like IFA distribution and Vitamin A supplementation, diarrhoeal disease control programme
through Oral Rehydration Therapy (ORT). Acute Respiratory Infections (ARI) Control Programme, etc. were implemented
over the past. In order to ensure maximum benefits from these programmes and to provide services in an integrated
manner to this vulnerable group the CSSM Programme was implemented.

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Despite all these efforts, the desired impact on the population growth and health, and development of women and
children in the country could not be achieved, and the need for a new approach to the problem was felt. International
conference on population and development (ICPD) held at Cairo in 1994, the nations of the world agreed to give special
E attention to reproductive health issue. ICPD recommended that new approach needs to be adopted to tackle the
o problem. Under this approach, it was decided that family planning services should be provided as a component of the
M comprehansive reproductive health care. ICPD defined reproductive health as a state of complete physical, mental and
&
social wellbeing and not merely the absence of disease or infirmity, in all matters relating to the reproductive system.
O
N Reproductive health approach implies that men and women be well informed about and have access to safe and
B effective contraceptive methods as well as women can go through pregnancy and childbirth safely and that couples are
B provided with best chance of having a healthy infant.

IN Following the recommendations of ICPD, being one of the 180 countries which participate in the conference, the
Government of India took the decision to launch a “Reproductive and Child Health (RCH) Programme in the 9th Five Year
plan. Accordingly to adopt the reproduction health approach to the population issues, India officially launched the
Reproductive and Child Health Programme in October 1997. In India, the RCH approach has been defined as “people have
the ability to reproduce and regulate their fertility, women are able to go through pregnancy and child birth safely, the
outcome of pregnancies is successful in terms of maternal and infant survival and wellbeing and couples are able to
have sexual relations free of pregnancy and of contracting diseases.”

The basic elements of Reproduction and Child Health Programme are:

Family planning
Maternal and child health.
Safe abortion services.
Effective control of STD and RTS
Prevention and management of infertility and
Prevention, detection cum treatment of reproductive tract malignancies.

The major factors affecting RCH are as follows:

Socioeconomic condition.
Status of women.
Educational opportunities.
Family environment.
Nutrition
Gender relationship and
Traditional and legal structure of society.

An extrinsic factor affecting RCH care service is the following:

Adolescent health.
Maternal mortality.
Unsafe abortion.
RTIs
STDs
AIDS
Infertility
Cancer
Empowerment of women.

THE PACKAGE OF SERVICES PROVIDED UNDER THE RCH PROGRAMME

RCH approach means that every couple should be able to have children when they want, that the pregnancy is uneventful,
that safe delivery services are available, that at the end of pregnancy, the mother and the child are safe and contraception
by choice are available to prevent pregnancy and contracting diseases. 13

CHILD SURVIVAL AND SAFE MOTHERHOOD

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1. For the mothers

Essential care for all

E Early detection of complications

o Emergency care for those who need it.
M
& 2. For the children
O Essential new born care
N
Exclusive breastfeeding and weaning
B
B Immunisation
Appropriate management of diarrhoea
IN
Appropriate management of ARI
Vitamin ‘A’ Prophylaxis
Treatment of anaemia

3. For eligible couples

Prevention of pregnancy through contraception services. safe abortion.
4. Prevention and management of Reproductive Tract Infection (RTI) and Sexually Transmitted Infections (STI's)
5. Adolescent health services including counselling of family life and reproductive health

SERVICES

ESSENTIAL CARE FOR ALL


Register by 12-16 weeks.
Antenatal check-up at least 3 times during pregnancy (20,32,36 weeks) The purpose of antenatal check-up is to
monitor progress of the pregnancy and to identify and refer high-risk cases for appropriate treatment at a hospital.
Tetanus toxoid immunisation should be given to all pregnant women as early as possible during pregnancy with two
doses at one month interval. If already immunised during the previous pregnancy, she should receive one dose of TT.
Give 1 tablet of IFA (Large) daily for 100 days to all pregnant women.
Treat those with clinical signs of anaemia with 2 tablets of IFA (large tablets for 100 days).
Deworm with mebendazole (during 2nd/3rd trimester) in areas where hookworm infestation is common.
Safe and clean delivery services.
Prepare the woman for exclusive breastfeeding and timely weaning.
Postnatal care, including advice and services for limiting and spacing births.

EARLY DETECTION OF COMPLICATIONS

Clinical examination to detect anaemia. Anaemia is not only a major cause for maternal mortality and morbidity but is
also major contributory factor for birth of a low birth-weight baby.
If there is bleeding before (APH) and excessive bleeding after delivery (PPH), she should be referred to the nearest
hospital by the quickest mode of transport.
Weight gain of more than 3 kg in a month or systolic blood pressure of 140 mmHg more should arouse suspicion of
pre-eclampsia. Such cases may also get fits (Eclampsia). All these cases are medical emergencies and should be
referred to the nearest hospital.
Fever 39°C and above after delivery or after abortion are normally due to infections and some times can be fatal. They
would also require treatment at a hospital.
Prolonged or obstructed about (labour pain for more than 12 hours) can lead to rupture of uterus. It is, therefore,
essential to take them to the nearest hospital where facilities for caesarian section are available.

EMERGENCY CARE FOR THOSE WHO NEED IT

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Early identification of obstetric emergencies.

Provide initial management and refer to identify referral hospitals minimum time should be wasted, as delay can be
fatal.
E
Use fast available mode of transport. The health workers must know the hospital where such cases can be treated and
o
M properly guide the attendants so that they can shift the patient by locally available quickest mode of transport by
& taking shortest route.
O While transporting such cases the patient should lie on her left side. In case the patient has fits, a roll of cloth should
N be placed between teeth to avoid tongue bite.
B
B

IN WOMEN IN THE REPRODUCTIVE AGE GROUP

Counselling on:
Importance of care of girl child.
Optimal timing and spacing of birth.
Small family norms
Use and choice of contraceptives
Prevention of RTIs/STDs. 14

Information on availability of
MTP services.
IUD and sterilisation services.

Provide family planning services.

Condom distribution
Oral contraceptives.
 IUD

Recognition and referral of RTIs/STDs

PROVISION OF CLEAN AND SAFE DELIVERY PRACTICES AT THE COMMUNITY LEVEL

Create awareness in the community on need for 5 cleans and safe deliveries.
Deliveries by trained personnels
Provision of Disposable Delivery Kits (DDKs) to all pregnant women.
Promotion of institutional deliveries.
Identification and referral of high-risk cases at the community level trained Dais.

INFANTS

NEW BORN CARE

Take birthweight of all new borns; Normal birth weight is above 2,500 gm. Babies whose weight is between 2,000 to
2,500 gm would require special care. Such babies are to be covered well with clothes and put close to the mothers,
breastfeed well and not to be handles by too many people in order to prevent infections. If the birth weight is less than
2,000 gm the new born must be referred to a medical officer for further examination and management.
Resuscitation of asphyxiated babies; The mucus trapped in the mouth should be gently sucked with the help of a
mucus sucker and give mouth-to-mouth respiration if necessary.
Prevention of hypothermia: Newborns are susceptible to catch cold.
After birth the newborn should be wiped dry and covered well with soft clean cotton cloth, which has been washed
with soap and dried in sun.
Exclusive breastfeeding within 1 hour of delivery; it is essential that the newborn is given the first milk as it contains
many essential nutrients and helps in developing immunity against diseases. The infant should be breastfed
exclusively and no other fluid need to be given till the age of 4 to 6 months when semisolid food should also be given.

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Referral of newborns, who signs of illness.

Advise the mother on essential newborn care, prevention of hypothermia and infections, nutrition (breastfeeding and
weaning), immunisation, vitamin A and early signs when to seek help.
E
o
M
& IMMUNISATION
O
N • BCG 1 dose at birth.
B
• DPT 3 doses beginning 6 weeks at monthly intervals
B
• Polio ‘0’ dose at birth for all institutional deliveries 3 doses beginning 6 weeks at monthly interval.
IN • Measles 1 dose at completion of 9 months of age.

• Vitamin A First dose (100,000 IU) with measles vaccination.

CHILDREN

IMMUNISATION

DPT/OPV booster dose at 16 to 18 months.

Vit. A
2nd dose (2,000,000 IU) at 16 to 18 months along with DPT/OPV booster.
3rd to 5th doses (2,000,000 IU) each at 6 monthly intervals.

IFA
 Small tablets if child has clinical signs of anaemia.

If suspected treatment for hookworm infestation.

PREVENTION OF DEATHS DUE TO DIARRHOEAL DISEASES

Correct case management for all cases of diarrhoea

Advise mother:
To give increased volume of fluids (ORS or HAF) as soon as diarrhoea starts.
How to prepare ORS solution.
Continue feeding the normal diet.
To recognise signs, when to seek help.

PREVENTION OF DEATHS DUE TO PNEUMONIA

Correct case management for all cases of acute respiratory infections.

Early initiation of cotrimoxazole to children with signs of pneumonia.
Referral of children with severe pneumonia or very severe illness. 15

REPRODUCTIVE TRACT INFECTION (RTI)/SEXUALLY TRANSMITTED INFECTION (STI)

RTIs include a variety of bacterial, viral and protozoal infections of the lower and upper reproductive tract of both sexes.
RTIs pose a threat to women's lives and wellbeing throughout the world. A high incidence of infertility, tubal pregnancy,
and poor reproductives outcome is an indirect reflection of high prevalence of RTIs/STIs in India.

Vaginal discharge is amongst the first 25 per cent to consult a doctor. Forty per cent gynaecological OPD attendance
is because of RTIs and 16% of gynaecological admissions are due to pelvic inflammatory disease (PID)

CAUSES OF REPRODUCTIVE TRACT INFECTION

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Infections caused by overgrowth of organism normally found in the vaginal tract is known as endogenous infections.
These infections are associated with inadequate personal, sexual and menstrual hygiene practices.
Sexually Transmitted Diseases (STDs) are a specific group of communicable diseases that are transmitted through
E sexual contact.
o
M Infections which are due to inadequate medical procedures such as unsafe abortion, unsafe delivery or unhygienic IUD
& insertion are known as iatrogenic infections.
O
N
B
B
SIGNS AND SYMPTOMS ASSOCIATED WITH RTIS IN WOMEN

IN Increased discharge from the vagina that looks and smells different from (change in amount, colour and smell).
Pain or burning while urinating.
Painful or painless sores, blisters or warts on or near the genitals.
Pain on one or both sides of lower abdomen.
Irregular menstrual periods.
Pain or bleeding during intercourse.
Rash on the entire body or just on the palms and soles.
Swelling on one or both sides of the groins.

IN MEN

Symptoms usually appear within 2 to 3 days or a couple of weeks or even months after having sex with an infected
partner are:

 Pus or discharge from the penis.

Burning or pain while urinating.
Painful or painless sores, blisters or warts on or near the penis.
Pain in one or both the testicles.

PREVENTION OF RTIS AND STI

Identify the women with RTI/STI.

Refer the women to medical officer of PHC promptly for examination and treatment.
Identify sexual partners and ensure their treatment.
Advice correct use of condom during every sexual act.
Provide counselling/health education to individuals, family and community.
Observe infection prevention measures amongst the health personnel.

A comprehensive RTI/STI control programme requires three levels of action:

Primary prevention.
Secondary prevention.
Tertiary prevention.

PRIMARY PREVENTION

Avoiding acquisition of infection through infected sexual partners. Strategy of primary prevention includes education and
counselling about safe sex practices, sexual hygiene and promotion of condom use. Use of condom prevents
transmission of RTIs/STIs.

SECONDARY PREVENTION

Secondary prevention aims at early detection of signs and symptoms and early referral of RTIs/STIs, so that spread of
infection to others is decreased. In the peripheral health care setting currently treatment is based on syndromic

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management. Counselling and education to motivate health seeking behaviour in community by reducing the number of
sexual partners, ideally sticking to single faithful sexual partner. Use of most appropriate antibiotics, practising proper
asepsis during reproductive interventions and education of sex partners.
E
o
M TERTIARY PREVENTION
&
O Tertiary prevention includes controlling complications of RTI. Strategies for tertiary prevention includes active screening
N
for presence of infection in high-risk group and appropriate management.
B
B Clinical management of septic abortion.
Transport for ectopic pregnancy.
IN
Management for infertility.
Cervical cancer screening. 16

Under the RCH Programme RTI/STI clinics are being set up in the FRU's and PHCs phase wise. The ANMs/LHVs will
be trained to provide RTI/STI services to the community. They will identify the RTI/STI cases and refer them to the PHCs
and to the nearest RTI/STI clinics. At the district level STD clinics will now treat RTI patient and are being assisted by
NACO. To make them client- friendly and easily accessible to women, district hospitals are asked to provide RTI services
in the gynaecology ward/post-partum centre.

CHILD WELFARE SERVICES IN INDIA

Child Welfare covers the entire spectrum of needs of children who by reason of handicapped—social, economic, physical,
or mental—are unable to avail of services, provided by the community. Child Welfare Programmes that seek to provide
supportive services to the families of those children because one of the important responsibilities of the society and
state, is to assist the family in its natural obligations for the welfare of the children. In India, we have a number of child
 welfare agencies, the important ones are:

Indian Council for Child Welfare.

Central Social Welfare Board.
Kasturba Gandhi Memorial Trust.
Indian Redcross society.

These agencies have got branches all over the country and they get financial aid from the government to organise
child welfare services in the country by arranging day care services, holiday homes, and recreation facilities for children.

In addition to national agencies, some international agencies also are interested in child welfare services, which
include:

UNICEF
World Health Organization.
International Union of Child Welfare.
CARE
FAO
UNO

INTEGRATED CHILD DEVELOPMENT SERVICES (ICDS)

The most important scheme in the field of child welfare is the Integrated Child Development Services (ICDS) scheme,
which was initiated in India in the Ministry of Social and Women's Welfare in 1975, in pursuance of the National Policy for
Children.

The ICDS seeks to lay a solid foundation for the development of the nation's human resources by providing an
integrated package of early childhood services. These consist of:

Supplementary nutrition.
Immunisation.
Health check-up.
Medical referral services.
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Nutrition and health education for women.

Non-formal education of children upto the age of 6 years and pregnant and nursing mothers in rural, urban and tribal
areas.
E
o ICDS scheme is designed both as a preventive and development effort. The objectives of the ICDS scheme are:
M
To improve the nutritional and health status of children in the age group 0 to 6 years.
&
O To lay the foundations for proper psychological, physical and social development of the child.
N To reduce mortality and morbidity, malnutrition and school dropout.
B
B To achieve an effective coordination of policy and implementation among the various departments working for the
promotion of child development.
IN To enhance the capability of the mother and nutritional needs of the child through proper nutrition and health
education.
To achieve the above objectives the ICDS aims as providing the following package of services:

Beneficiary Services

Pregnant women – Health check-up

– Immunisation against tetanus
– Supplementary nutrition.
– Nutrition and health education

Nursing mothers – Health check-up

– Supplementary nutrition
– Nutrition and health education

Other women 15-45 years – Nutrition and health education

Children less than 3 years – Supplementary nutrition.

– Immunisation.
– Health check-up
– Referral Services.

Children in age group 3 to 6 years – Supplementary nutrition.

 – Immunisation
– Health check-up
– Referral services.
– Nonformal education.
17

The strategy adopted in ICDS is one of the simultaneous delivery of early childhood services. While the health
component forms a major component, ICDS is much more than a mere health programme for delivery of social service
input for development. The administrative unit of an ICDS project is the community development block in rural areas, the
tribal development block in tribal areas and a group of slums in urban areas. The focal point for the delivery of integrated
early childhood services under the ICDS scheme, is the trained local women known as “Anganawadi Worker” (AWW).
Other functionaries in ICDS scheme are CDPO, who is in-charge officer for supervisors (Mukhya Sevikas) of 100 AWW.

NUTRITION PROGRAMMES

The Government of India have initiated several large scale supplementary feeding programmes, and programmes aimed
at overcoming specific deficiency of diseases through various ministries to combat malnutrition including the Ministry of
Health and Family Welfare, the Ministry of Social Welfare and the Minsitry of Education.

The major factors leading to malnutrition in India include inadequate intake of calories and proteins, deficiency of
certain micronutrients (like iron, vitamin A, calcium or iodine), maldistribution of essential food commodities, low
purchasing power, lack of knowledge about balanced nutrition and limited access to health care facilities. The vicious
cycle of poverty malnutrition and ill-health has to be combated through the integrated efforts of socio-economic
development, better nutrition is widely prevalent, especially amongst those who live below poverty line. The worst hit are
pregnant and lactating mothers and children below six years of age, because of additional requirements and their
vulnearable condition, they are more prone to infection and malnutrition.

Dietary survey in the low socio-economic groups have shown a dietary deficit of 500 to 600 calories in women, and
1000 to 1100 calories in pregnant and lactating mothers. This maternal malnutrition leads to “Low birth weight” babies.
The average birth weight of newborn in the lower socio-economic groups 2.7 kg as compared with 3.1 kg in higher socio-
economic groups. Low birth weight babies have a worse mortality experience, being more vulnearable to infection.
Malnutritions directly or indirectly responsible for over 50 per cent die of severe protein calorie malnutrition every year.
And 50 per cent pregnant women in the third trimester have a haemoglobin level of less than 10 grams per cent, anaemia
in pregnancy is directly responsible for 20 per cent of all maternal deaths, and indirectly for 20 per cent of all maternal
deaths, and indirectly for a much larges proportion. Over 60 per cent of children under 6 years of age suffer from some

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form of nutritional anaemia and PEM. Vitamin A deficiency is responsible for at least 25,000 children becoming blind
every year. About 40 millions people are estimated to be affected by goitre in India.

E In view of the high prevalence of malnutrition in India, the Government has launched several nutritious programmes
o at the national level. The following are the major nutrition programmes that are being implemented in India:
M ICDS Scheme
&
O National Nutritional Anaemic Prophylaxis Programme
N National Goitre Control Programme
B
National Programme for Prevention of Nutritional Blindness due to Vitamin A deficiency.
B
Mid-day Meal Programme.
IN Special Nutrition Programme
Allied Nutrition Programme
Chief Minister's Noon Meal Programme (Tamil Nadu).

ICDS SCHEME

ICDS scheme already explained in earlier. It is more than a mere nutrition programme and aims at total development of
the child. ICDS consists of growth monitoring, and supplementary nutrition is given for 300 days a year, by on-the-spot
feeding as far as possible. All beneficieries receive daily ration of 300 kilocalories and 8 to 10 grams protein.

Severely malnourished children and pregnant and lactating mothers receive daily supplementary nutritions providing
60 kcal. and 18 to 20 grams of protein. In this programme, Vitamin ‘A’ prophylaxis and IFA distribution also are included. 18

SPECIAL NUTRITION PROGRAMME (SNP)


Special nutrition programme was launched in 1970, as a crash programme to provide supplementary nutrition to children
below 6 years of age, and pregnant and lactating mothers. The socially and economically handicapped are to be reached
through this programme, as well as those in slums, drought prone and flood affected areas. It is now envisaged that the
special Nutrition programme should include some of the components of the ICDS, in order to render it more effective.
Properly selected target groups of mothers and children are to be supported with basic health inputs, including nutrition
and health education.

The objectives of the programme is to improve the nutritional status of pregnant and lactating mothers and children
below 6 years of age in the weakest sections and most vulnerable areas. The objectives are now to include a reduction in
mortality and morbidity in children below 6 years, enhance the capacity of mothers to look after the daily health and
nutritional needs of children and to strengthen the supportive services. The main activities of the programme are:

To provide supplementary nutrition

To provide health services including supply of vitamin A solution and iron and folic acid tablets (Since 1976).

This programme is for the nutritional benefits of children below 6 years of age, pregnant and nursing mothers and is
in operation in urban slums, tribal areas, and backward rural areas. The supplementary food supplies about 30 kcal and
10 to 12 grams of protein child per day. The beneficiary mothers receive daily 500 kcal and 25 grams of proteins. This
supplement is provided to them for 300 days in a year. This programme is gradually merged into ICDS.

NATIONAL NUTRITIONAL ANAEMIA PROPHYLAXIS PROGRAMME (NNAPP)

Nutritional anaemia is one of the important health problems, affecting women and children in India. ICMR study (1965)
shows that about 50 per cent of children under 5 years and 50 per cent pregnant and lactating mothers have
haemoglobin level less than 10.5 grams per cent. To start with, the NNAPP had no set goals. Under this programme,
anaemia mothers and children are given IFA tablets. The tablets for mother contain 60 mg iron and 500 micrograms folic
acid and those for children contain 20 mg iron and 100 micrograms folic acid. Tablets are distributed to mothers and
children if their haemoglobin is below 10 gm% and 8 gm% respectively. For young children who cannot swallow, liquid
preparations containing the same amount of IFA (2 ml at a time) is given. The good progress have been achieved through
this programme. The specific objectives as identified from general description of the programme are as follows:

To assess the baseline prevalence of nutritional anaemia in mothers and young children through estimation of Hb
levels.

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To put the mothers and children with low Hb levels (less than 10 gm% and less than 8 gm%) on anti-anaemic
treatment.
To put the mothers with Hb levels more than 10 g/dl and children with more than 8 gm/dl on the prophylaxis
E programme.
o
M To monitor continuously the quality of the tablets, distribution and consumption, and to assess periodically the Hb
& levels of the beneficieries.
O To motivate mothers, through relevant education, to consume the IFA tablets and to give the same to their children.
N
B
B
NATIONAL GOITRE CONTROL PROGRAMME (NGCP)
IN
The government of India realising the magnitude of endemic goitre launched the NGCP in 1962. It aimed at replacement
of ordinary salt by iodised salt, particularly in goitre endemic regions. Surveys indicated that the problem of the goitre
and iodine deficiency disorders was more widespread than it was thought earlier, with nearly 145 million people
estimated to be living in known endemic areas of the country. As a result, the programme was mounted in 1986 with
objective to replace the entire edible salt by iodine salt in a phased manner by 1992. The objectives of NGCP are:

Initial survey to assess the magnitude of the iodine deficiency disorders.

Supply of iodised salt in place of common salt to the entire country by 1992.
Repeat surveys to assess the impact of iodised salt after 5 years.

Accordingly the programme has been implemented, and shown some progress. But reveals strengthening of NGCP
in the areas related to: 19

1. Irregular distribution of iodised salt for varying periods.

2. Lack of supportive supervision for the quality of iodised salt distributed.
3. Failure of lifting of the allotted quotas of iodised salt by wholesale agents for further distribution to retailers.

4. Poor interpersonal relationship between salt dealers and food inspectors, the implementation of PFA act.
5. Co-ordination between department of food and civil supply, health and wholesale dealers.

NATIONAL PROGRAMME FOR PROPHYLAXIS AGAINST BLINDNESS DUE TO VITAMIN ‘A’ DEFICIENCY

The National Programme for Prophylaxis against Blindness due to Vitamin ‘A’ deficiency was launched in 1970 under the
Ministry of Health as a part of MCH Programme. Studies have been shown that in the southern and eastern parts of the
country, about 30 to 50 per cent pre-school children have eyes problems as a result of Vitamin ‘A’ deficiency. It is
estimated that 2 per cent of the total blindness in India is caused by Vitamin ‘A’ deficiencies.

The specific objective of the programme in reduction of disease and prevention of blindness due to vitamin ‘A’
deficiency; An evaluation of the programme has shown than in areas where it has been implemented well there was
significant reduction in the prevalence of signs of vitamin ‘A’ deficiency. The reasons for poor coverage have been
inadequate supplies of vitamin ‘A’ and adoption of clinic approach instead of house-to-house visit for the distribution. As
a part of RCH Programme (earlier CSSM) attention now focussed upon children upto 3 years of age.

BALAWADI NUTRITION PROGRAMME

The Balawadi Nutrition Programme was started in 1970-71, with the pre-school child as its target. It is operated through
Balawadis and day care centres, and is under the charge of the Social Welfare Department.

The objective of the programme is to supply one-fourth of the calorie requirements and half of the protein
requirements of the pre-school child as a measure to improve the nutritional status. It is to be a supplement to what the
child receives at home. As far as possible, locally available food stuff is to be utilised. Children belonging to the lower
socio-economic group would be selected. Community involvement would be encouraged.

The nutrition supplement providing 300 calories and 10 grams of protein per child per day for 270 days a year, in
provided in Balawadis or day care centres where some non-formal education of the pre-school child is given. It is
envisaged that a package including basic health components are to be included as in the ICDS.

This programme is directed by the Ministry of Social Welfare through several voluntary organization. Balawadi is
managed by Balsevikas assisted by helper, coordination committees at the centre, state, district, block along with the
community, are to ensure regular supply of resources and effective management.
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MID-DAY MEAL PROGRAMME (MDMP)

E
o The Mid-day Meal Programme started in India in 1925 in Chennai as part of the People's movement. It picked up
M momentum and the Government on a nationwide basis, stepped it up in 1962-63. Care started assisting the programme
& in 1961. The Mid-day Meal Programme gives supplementary food to children aged 6 to 11 years in primary schools. Food
O is given for 200 days a year and ration of 38 lb per year per child.
N
B The objectives of the programme is to providing food to meet the gap in nutritional requirements particularly in poor
B
children. This would help the children, not only improving the nutritional status, but also improve their performance at
school. It would indirectly act as an incentive for sending children to school.
IN
In this programme, each primary school child is given food for 200 days. This is to be an addition to what the home
provides. This programme is co-ordinated and implemented by the Ministry of Education.

As stated earlier, the major objectives of the programme is to attract more children for admission to schools and
retain them so that literacy improvement of children could be brought about. In formulating mid-day meals for school
children, the following broad principles should be kept in mind:

The meal should be a supplement and not a substitute to the home diet. 20

The meal should supply at least one-third of the total energy requirement and half of the protein need.
The cost of the meal should be reasonably low.
The meal should be such that it can be prepared easily in schools; no complicated cooking process should be
involved.
As far as possible, locally available foods should be used, this will reduce the cost of the meal.
The menu should be frequently changed to avoid monotony.

 A model menu for a mid-day school meal will be:

Food stuff gram/day/child

Cereals and millets 75

Pulses 30

Oils and fats 8

Leafy vegetables 30

Non-leafy vegetables 30

This Mid-day Meal Programme become the part of the Minimum Needs Programme in the fifth FYP.

APPLIED NUTRITION PROGRAMME (ANP)

Improvement in nutritional status depends largely upon awareness and knowledge as well as availability of food. The
erstwhile expanded programme of nutrition started in India in 1960. It was started first in Orissa and Andhra Pradesh,
and extended in 1960 to Tamil Nadu and in 1962 to Uttar Pradesh. In 1963, the ANP was extended to the whole country
through the Government of India, along with aid from UNICEF with the active participation of the states.

The programme was launched in 1963 to combat malnutrition in vulnearable groups, particularly mothers and
children in rural areas. The programme was basically an education oriented programme, operational at the village and
family level.

The main objectives of the programme are:

To make people conscious of their nutritional needs.

To increase production of nutritious foods and their consumption.
To provide supplementary nutrition to vulnerable groups through locally produced foods.

The main components of the ANP are:

Production of protective foods.

Training of functionaries involved in the production of these foods.
Nutrition education and demonstration (demonstration of improved technique of cooking and feeding were also used).

The programme is coordinated by the Ministry of Rural Reconstruction.

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At the state level the Panchayatraj and community development is generally in-charge of the programme and in the
field, block development officer's incharge of the programme.

E The activities of the Applied Nutrition Programme will include:

o Kitchen gardens, school gardens and community gardens are set up to promote the concept of a balanced diet, as well
M as to increase production
&
O Fishery units and poultry units are set up. This gives employment, added income and more production of food (poultry
N farming, beehive keeping), etc.
B Providing better seeds as well as well-breed cattle were provided.
B
Supplementary feeding, through local food production was given to vulnerable pregnant in lactating mothers and
IN children.
Panchayats, Yuvak and Mahila Mandals were to be involved to promote community participation.
Training for horticulture and pisciculture were given.
Non-formal pre-school education.

Evaluation studies showed that ANP has not generated the desired awareness for production and consumption of
protective foods. The community kitchen gardens and school gardens could not function properly due to lack of suitable
land, irrigational facilities and low financial investments. The scheme of setting up of poultry units and pisciculture also
did not make much headway. The adequate infrastructure for co-ordination implementation and monitoring was not
developed at the field and district level. Therefore, the programmes lacked effective supervision and has almost become
defunct.

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