Current Trends in

UNIT 1 CURRENT TRENDS IN MATERNAL Maternal Nursing

NURSING
Structure

1.0 Objectives
1.1 Introduction
1.2 Maternal Nursing — Historical Perspective
1.2.1 Concepts of Maternal Nursing
1.2.2 Scope of Maternal Nursing
1.3 Family Welfare Services
1.3.1 Demographic Trends in India
1.3.2 Factors Influencing Fertility in India
1.3.3 Population problems of India
1.3.4 How to control population of India
1.3.5 National Family Welfare Programme
1.3.6 National population policy
1.3.7 Child survival and safe motherhood programme
1.3.8 Reproductive and child health programme
1.3.9 Millennium development goals
1.3.10 National Rural Health Mission
1.3.11 National Health Policy
1.4 Organisation and Administration of Family Welfare Programme
1.5 Role of Nurse in Family Welfare Services
1.6 Let us Sum Up
1.7 Answers to Check Your Progress

1.0 OBJECTIVES
After completing this unit, you should be able to:
• Describe the trends in Maternal Nursing;
• State the demographic trends in India;
• Explain the factors influencing the fertility in India;
• Explain the national family welfare programme;
• Explain the population policy 2000
• Explain National Health Policy of India since 1983
• Discuss the role of nurse in providing quality family welfare services.

1.1 INTRODUCTION
Every year approximately 2,00,000 million women become pregnant in developing
countries and more than 295,000 of them die of pregnancy related causes and
million suffer a significant complication of pregnancy. Additionally, seven million
perinatal deaths occur as a result of maternal health problem (WHO). 11
Nursing Management in A woman’s health before and after pregnancy is particularly important, not only
Maternal Health
because she remains healthy but also because her health will largely determine
the health of her baby at birth and in the future. Achieving health for women and
children determines the health of family and in turn country at large.
Hence we learn from our past and implement our strategy in present and change
the scenario in future by our continuous efforts. In this unit you will identify the
trends in maternal nursing and family welfare services which help in reducing
maternal mortality rate.

1.2 MATERNAL NURSING — HISTORICAL

PERSPECTIVE
In this section of maternal nursing and historical perspective we will acquaint
you on concept and scope of maternal nursing. It also deals with the development
of maternal nursing in India.
Maternal Nursing in the Western World
The roots of maternal care in the Western World are also ancient. The first recorded
obstetric practices are found in Egyptians records dating back to 1500 BC.
Practices such as vaginal examination and the use of birth aids are referred to in
writings from the Greek and Roman empires, but much of that information was
lost in Dark Ages.
Socrates regarded Midwifery as a noble profession. His own mother was a
midwife. Significant discoveries and inventions by physicians in 16th and 17th
centuries set the stage for scientific progress. The prominent discovery include
obstetric forceps which were first devised by Peter Chamberlin (1560-1631) and
modified by William Smellie (1697-1763). Francois Mauriceau (1637-1709) noted
that puerperual fever or “childbed” fever was an epidemic disease.
The trends in west suggest that midwives were regarded not as part of the medical
establishment but as a separate profession with a unique social role and had
formal training and licensing for midwifery.
From time to time educated women, daughters of medical men and clergy men
became midwives and obstetrical college for women was founded in London in
1864. Florence Nightingale was pioneer in the efficient training of midwives. In
1862 she organised a small training school in connection with King’s College
Hospital but the wards were inconvenient and the scheme was not a success due
to outbreaks of puerperal pyrexia. At about this time Sommelweis introduced
better caring practices such as hand washing technique with chlorine and lime
before attending women at childbirth.
A Board for the examination of midwives was constituted in London and the
first examination was held in 1872 for six candidates.
The General Medical Council team from 1872 onwards made great efforts to
secure state recognition of midwives. The midwives institute was established in
1881 with the objective of gaining some sort of recognition from the state.
The Bill on recognition of midwifery was passed on 31st July, 1902 in the
Parliament in London.
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Maternal Nursing in India Current Trends in
Maternal Nursing
In Ancient India the care of women during childbirth was carried out by the
Indigenous village dais. The occupation of dais was carried in families and they
were trained by their mothers or mother-in-laws. By and large this work was
done by the lower caste women of the society. There was no formal training
given to women to carry out midwifery practices and hence they were unable to
handle the complications related to childbirth resulting in increased morbidity
and mortality.
As early as in 1877 Miss. Hewlett of Zanana Missionary Society started the first
training school for dais in Amritsar. Later on these trainees were also helped by
a fund initiated by Lady Curzon to improve the conditions of childbirth in the
country in 1900.
Madras Presidency succeeded to enact the Registration of Nurses and Midwives
Act, 1926 to promote a registered midwife for service during child birth. The
midwifery training was imparted in hospitals by only Anglo Indian nurses. At
that time most of the students were from Indian Christian Community. The real
change in the field of maternal nursing came after creation of Dufferin fund.
In the initial phase, it was difficult to get Indian girls for training. Dufferin fund
sanctioned grants to various hospitals to build hostel and supply teaching material
and employ qualified sisters in nursing schools. This fund was a great help to
raise standards of midwifery practices in the country.

1.2.1 Concepts of Maternal Nursing

In the Western World there was a shift from home confinement to hospital after
the second World War. Following the publication of the Peel Report in which
100% hospital confinements were advocated in an attempt to reduce perinatal
mortality (Robinson, 1990) by 1970.
The midwifery training which was initially started with diploma raised to a degree
level and made to reach to Masters and Ph.D. level. Consequently the amount of
research which is directly related to maternal nursing is growing as a result of
these advanced programmes of study.
Today midwifery (Maternal Nursing) has developed from being merely a group
of handy women who helped the mothers to give birth, into a well educated and
respected profession in which there are many opportunities.
Midwives have opportunities to render care in variety of ways. For instance, they
may be attached to midwifery team, or one to one service of an independent
practice. Whatever the pattern of care, the aims are the same to give high quality
services in maternity care.
Present Concept of Maternal Nursing in India
Prior to independence, midwifery training had started as a separate course in
India. Young girls qualifying at the middle school (Class-VIII) level were selected
to undergo this training.
In 1946, the Bhore Committee reported lack of skilled services by qualified
midwives as one of the causes for high maternal and infant deaths. This committee
laid foundation for public health planning and emphasized on the need for qualified
midwives and health visitors. 13
Nursing Management in A few years later in 1955, Shetty Committee recommended training and posting
Maternal Health
of ANMs in MCH centres. These ANMs were to be supervised by the Lady
Health Visitors.
Bishcoff in 1959 suggested two types of training in the country. One was Auxillary
Nurse Midwifery and another one was General Nursing and Midwifery.
Since independence there was a great deal of change in nursing education. After
the inception of Indian Nursing Council in 1947 the General Nursing and
midwifery was combined as one training of 3 years and six to nine months
duration.
The second change brought about was to replace diploma in midwifery to ANM
course of 2 years duration. Later on, based on the recommendation of Kartar
Singh Committee in 1975, the ANM was given added responsibility of
participating in all the national programmes i.e. health promotion education,
immunization, nutrition education to community, national malaria control
programme, and prevention of blindness etc. Nomenclature of ANM was changed
to Multipurpose Health Worker. The duration of course was also reduced by six
months thus making it 18 months programme. This change diluted the care
provided to women during pregnancy and child birth.
The progressive dilution of midwifery led to increased MMR in India. Therefore
inspite of establishing huge network of sub-centres in India maternal care did not
improve to the expected levels. The emphasis on family planning, target
achievements and the rigid tubectomy case load was detrimental to providing
timely midwifery services resulting in a skewed priority of functions
(Prakashamma,1989).
The maternal nursing practice in the hospital setting has become an appendage
to the obstetrics. But, midwives exerting autonomy to exercise independent
practices are still rare.
Recently, the Indian Nursing Council has introduced the Post Basic Diploma in
Nurse Practitioner in Midwifery, a one year course in midwifery post BSc nursing
training. The course was adopted by the States of West Bengal and Gujarat.

1.2.2 Scope of Maternal Nursing

Global evidence has shown that the care given by midwives has historically
translated in to improved quality of maternal and new born health services, and
has significantly reduced maternal and neonatal mortality and morbidity.
The midwifery nursing practices are influenced by government policies and to
some extent by politics or organisations e.g., NIHFW. They are also affected by
various financial constraints. The services are always necessary as women
delivering babies and becoming pregnant are natural processes. They require
professional assistance – and increasingly it is the consumers of the services who
expect/dictate what those services should be and how they should be delivered.
Midwives (Maternal Nurse) need strength and insight to act as the mother’s
advocates, whilst recognizing the need for the couple (parents) to decide on their
matters concerning their family welfare. This new relationship should, however,
facilitate a return to the literal meaning of the word “midwife” of being “with
woman”.
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Future of Maternal Nursing in India Current Trends in
Maternal Nursing
The launching of the Reproductive and Child Health Programme and the shift in
policies from demographic targets to comprehensive reproductive health services
provides the right atmosphere to make a positive change in the type and quality
of services.
A report of WHO study group (1994) predicted “nurses with highly specialized
training would be involved in the high technology tertiary care. For example, the
work of community midwife will involve education about safe delivery as well
as development of women’s health care programme that would include planning,
nutrition and healthy child birth”.
Midwifery training practice regulation and standard setting processes are
undergoing rapid changes in neighbouring countries.
Since maternal nursing specialists have to be accountable for their actions and
decisions taken by them independently, regulatory bodies and professional
organizations like Indian Nursing Council, TNAI (Trained Nurses Association
of India) have to enact such regulations to enable maternal nursing practitioners
to redirect their practice to meet changing health care needs. The maternal nursing
expert would be called upon to manage the obstetric and neonatal emergencies.
All the more after introduction of Consumer Protection Act in India, the
independent practice and autonomy should be observed very carefully.
The Government of India, professional organisations and nurses will have to
join hands to come up with a long term plan of action to reduce maternal deaths
through skilled maternal nursing services in rural and urban areas.
Midwifery has to be separated from being a branch of nursing or an appendage
of obstetrics and should receive an independent identity in view of the crucial
nature of its role in the health of mothers and children to reduce maternal and
infant mortality in our country.
Since maternal nursing is a practice based profession, maternity nurses/midwives
need to constantly engage in action research. It is essential to develop a body of
scientific and evidence based knowledge and practices for maternal nursing
(Hicks, 1996).

1.3 FAMILY WELFARE SERVICES

As you know India has already crossed one billion mark in its population and
may soon become the first country in the world to have such huge population.
This will greatly strain the resources available in all spheres of daily life. You as
a health personnel must take more responsibility to help the country to bring
down the population growth. In this unit we will familiarize you about family
welfare services and programme available in India. You will also learn about
various contraceptives. At the end of this sub-section we will discuss about national
family welfare programme and its objectives.
The population of the world is increasing in an exponential manner. India is the
second most populous country in the world next to China and seventh in land
area. India has only 2.4% of world’s population with annual growth of 2.1%.
About 16 million people are being added every year to the already grown
population. 15
Nursing Management in High birth rate and declining death rate leads to population explosion resulting
Maternal Health
in low standard of living, shortage of food supply and malnutrition.
India with its high birth rate and low death rate is facing the above problems of
population explosion
Family planning as an official programme was adopted in 1952 considering the
fact that a rapidly growing population would be more of a hindrance than help in
raising the standard of living of people.

1.3.1 Demographic Trends in India

With the population of 1.21 billion in 2011 India is the 2nd most populous country
in the world. India’s population has been steadily increasing since 1921. The
year 1921 is called the “Big Divide” because the absolute number of people
added to the population during each decade has been on the increase since 1921.
India’s population is currently growing at an average annual rate of 1.2%.
At the time of Independence in 1947, the population of India stood at 344 million
and within 34 years it doubled and in the year 2011 India’s population stood at
1.21 billion. Currently India is in the ‘late expanding stage’ (Birth rate is nearly
constant and death rate is decreasing) of demographic cycle.

1.3.2 Factors Influencing Fertility in India

The word fertility means the actual bearing of children. Fertility depends on various
factors which are as follows :
i) Age at marriage : The age at which female marries and enters reproductive
period of life has a great impact on her fertility. In India the average age at
marriage for girls is 18 years, due to which she has a larger reproductive life
span and hence giving birth to more children.
ii) Duration of married life: Studies indicate that 10% to 25% of births occur
within 1-5 years of married life, 50-55% of births within 5-15 years and
births after 25 years are rare. So duration of married life has an impact on the
child bearing of women.
iii) Spacing of children : Studies have shown that if all the births are postponed
by one year in all the age groups there is a decline in fertility, which shows
that spacing of children will help in reducing the population growth.
iv) Education : There is a close association between fertility and education. In
states where women are more educated there is a decline in birth rate. Probably
because she uses her judgement and takes decision regarding child bearing
and rearing.
v) Economic status : Economic status has an inverse relationship with fertility.
Higher the economic status lesser the number of children.
vi) Caste and Religion: Muslims have a higher fertility rate than Hindus.
vii) Nutrition : Virtually all well fed societies have low fertility and poorly fed
societies have high fertility. The effect of nutrition is indirect.
viii) Family Planning : Family planning is another important factor in fertility
reduction.
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ix) Other factors : Fertility is affected by a number of physical, biological, Current Trends in
Maternal Nursing
social and cultural factors such as status of women in society, value of children,
gender biasness, widow remarriage, breast-feeding, custom and opportunities
for women.

Check Your Progress 1

1) Fill in the blanks:
i) Bhore Committee emphasized on qualified ....................................
ii) Indian Nursing Council was established in .....................................
iii) Multipurpose Health Worker Scheme was recommended by
..........................................................................................................
2) Explain briefly the scope of maternal nursing in India?
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3) Describe factors influencing fertility in India.
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1.3.3 Population Problems of India

Effects of excessive population in India are as follows:
1) Environmental Pollution
2) Urbanization
3) Water Supply
4) Food scarcity
5) Economic growth

1.3.4 How to control population growth in India

1) Use of financial assistance for family planning
2) Female Education and Employment
3) Delaying and increasing the age of marriage
4) Provision of family planning services and methods at all levels of health
care e.g. PHC,CHC etc.
5) Educate people to adopt small family norms using mass media and various
other means of health education.
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Nursing Management in 1.3.5 National Family Welfare Programme
Maternal Health
India launched its first nationwide family planning programme in the year 1952
though the records show that the birth control clinics were functioning since
1930.

An expert committee of WHO (1971) defined family planning as a way of thinking

and living that is adopted voluntarily upon the basis of knowledge, attitudes and
responsible decision by individuals and couples, in order to promote the health
and welfare of the family group and thus contribute effectively to the social
development of a country.
The Objectives of Family Welfare Programmes are to:

• avoid unwanted births

• bring about wanted births

• regulate the interval between pregnancies

• control the time at which births occur in relation to the ages of parents
• determine the number of children in the family.

Scope of Family Welfare Services

Now we shall see what are the scope of Family Welfare Programme. They are as
follows:
i) Proper spacing and limitation of birth

ii) Advice on sterility

iii) Education for parenthood

iv) Sex Education

v) Screening for pathological conditions related to the reproductive system

vi) Genetic Counselling

vii) Carrying out pregnancy tests

viii) Premarital consultation and examination

ix) Marriage Counselling

x) Preparation of parents for arrival of the baby

xi) Providing services to unmarried mothers

xii) Teaching home economics and nutrition

xiii) Provision for adoption services

Family planning has a direct effect on the health of mother and children.
Contraception helps mother to regain health in between the pregnancies which
in turn will help in better health during foetal life and hence a healthy infancy
and childhood.
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1.3.6 NATIONAL POPULATION POLICY Current Trends in
Maternal Nursing
Government of India launched the National Population Policy (NPP) in 2000 to
improve quality of lives of people of India and to provide them with equal
opportunities to be productive assets of society.
In 1952 India was the first country in the world to launch a national programme
to emphasize the need for family planning for reducing birth rate to stabilize the
population at a level consistent with the requirement of national economy. A
sharp decline in the death rates after 1952 were not accompanied by a similar
drop in birth rates. Therefore National health policy 1983 stated that replacement
levels of TFR (total fertility rate) should be achieved by the year 2000. The
government realised that the latter is basically a function of making reproductive
health care accessible and affordable for all, providing primary and secondary
education, etc. All this also essential for creating sustainable development
model.
It was projected that if current trends in population growth continue, India may
overtake China in 2045 to become the most populous country in the world thus
neutralizing all efforts to conserve the resource endowment and environment.
The National Population Policy (NPP) 2000 provides a policy frame work of
achieving goals and prioritizing strategies during the next decade to meet the
reproductive and child health needs of the people of India along with the target to
achieve the net replacement levels (Total Fertility Rate). It aims at stable population
by 2045.
Objectives of NPP
The following national socio-demographic goals were formulated to be
achieved by 2010:
1) To address the unmet needs for basic reproduction (contraception), child
health services, supplies and infrastructure (health personnel).
2) To make school education up to age 14 free and compulsory and reduce
dropouts at primary and secondary school levels to below 20 per cent for
both boys and girls.
3) To reduce infant mortality rate to below 30 per 1,000 live births.
4) To reduce maternal mortality rate to below 100 per 100,000 live births.
5) To achieve universal immunization of children against all vaccine preventable
diseases.
6) To promote delayed marriages for girls, not earlier than age 18 and preferably
after 20 years of age.
7) To achieve universal access to information/counseling, and services for
fertility regulation and contraception with a wide basket of choices.
8) To achieve 80 per cent institutional deliveries and 100 per cent deliveries by
trained persons.
9) To achieve 100 per cent registration of births, deaths, marriages and
pregnancies.
19
Nursing Management in 10) To prevent and control communicable diseases, especially AIDS and sexually
Maternal Health
transmitted infections (STIs).

11) To promote vigorously the small family norm.

12) To integrate Indian Systems of Medicine (ISM) in the provision of

repro-ductive and child health services, and in reaching out to households.

Strategies of NPP

1) Decentralised Planning and Programme Implementation

2) Convergence of Service Delivery at Village Levels

3) Empowering Women for Improved Health and Nutrition

4) Prioritizing and intensifying measures for child Health and Survival

5) Meeting the Unmet Needs for Family Welfare Services

6) Special attention on under-Served Population Groups e.g. people living in

slums, tribal population and adolescents
7) Increase the numbers and diversify the categories of health care providers.

8) Collaboration with and Commitments from Non-Government Organisations

and the Private Sector

9) Mainstreaming Indian Systems of Medicine and Homeopathy

10) Contraceptive Technology and Research on Reproductive and Child Health

11) Providing for the Older Population

12) Information, Education, and Communication

Legislation, Public Support & New Structures

As a motivational measure, in order to enable state governments to fearlessly

and effectively pursue the agenda for population stabilisation contained in the
National Population Policy, 2000, one legislation was considered necessary. It
was recommended that the 42nd Constitutional Amendment that freezes till 2001,
the number of seats to the Lok Sabha and the Rajya Sabha based on the 1971
Census be extended up to 2026.

PUBLIC SUPPORT in these matters can be achieved by demonstration of strong

support to the small family norm by political, community, business, professional
and religious leaders, media and film stars, sports personalities, and opinion
makers. They will enhance its acceptance throughout society. The government
will actively enlist their support in concrete ways.

The NPP 2000 is to be largely implemented and managed at Panchayat and Nagar
Palika levels, in coordination with the concerned state/Union Territory
administrations. Accordingly, the specific situation in each state/UT must be kept
in mind. This will require comprehensive and multisectoral coordination of
planning and implementation between health and family welfare on the one hand,
20 along with schemes for education, nutrition, women and child development, safe
drinking water, sanitation, rural roads, communications, transportation, housing, Current Trends in
Maternal Nursing
forestry development, environmental protection, and urban development.
Accordingly, the following structures were recommended:
National Commission on Population:
A National Commission on Population, presided over by the Prime Minister,
will have the Chief Ministers of all states and UTs, and the Central Minister
in charge of the Department of Family Welfare and other concerned Central
Ministries and Departments, for example Department of Woman and Child
Development, Department of Education, Department of Social Justice and
Empowerment in the Ministry of HRD, Ministry of Rural Development,
Ministry of Environment and Forest, and others as necessary, and reputed
demographers, public health professionals, and NGOs as members. This
Commission will oversee and review implementation of policy. The
Commission Secretariat will be provided by the Department of Family
Welfare
State / UT Commissions on Population:
Each state and UT may consider having a State / UT Commission on
Population, presided over by the Chief Minister, on the analogy of the National
Commission, to likewise oversee and review implementation of the NPP
2000 in the state / UT.
Coordination Cell in the Planning Commission:
The Planning Commission will have a Coordination Cell for inter-sectoral
coordination between Ministries for enhancing performance, particularly in
States/UTs needing special attention on account of adverse demographic and
human development indicators
Technology Mission in the Department of Family Welfare:
To enhance performance, particularly in states with currently below average
socio-demographic indices that need focused attention, a Technology Mission
in the Department of Family Welfare will be established to provide technology
support in respect of design and monitoring of projects and programmes for
reproductive and child health, as well as for IEC campaigns.

Check Your Progress 2

1) Enlist population problems of India.
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2) List five Objectives of national population policy 2000.
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Nursing Management in
Maternal Health 3) Enumerate any five strategies of National Population Policy 2000.
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1.3.7 Child survival and safe motherhood programme (CSSM)

The Child Survival and Safe Motherhood Programme jointly funded by World
Bank and UNICEF was started in 1992-93 for implementation up to 1997-98.
The Child Survival and Safe Motherhood Programme was implemented in a
phased manner covering all the districts of the country by the year 1996-97. The
objectives of the programmes were to improve the health status of infants, child
and reduction of maternal morbidity and mortality. The programmes seek to sustain
high coverage levels achieved under the Universal Immunisation Programme
(UIP) in good performance areas and strengthen the immunisation services of
poor performing areas. The programme also provides for augmenting various
activities under the Oral Rehydration Therapy (ORT) Programme, universalising
prophylaxis schemes for control of anaemia in pregnant women & control of
blindness in children and initiating a programme for control of acute respiratory
infection (ARI) in children. Under the safe motherhood component, training of
traditional birth attendants (TBA), provision of aseptic delivery kits and
strengthening of first referral units to deal with high risk and obstetric emergencies
were taken up. The Programme yielded notable success in improving the health
status of pregnant women, infants and children & also making a dent in IMR,
MMR and incidence of vaccine preventable diseases.

1.3.8 Reproductive and child health programme- Phase-I

World Health Organization (WHO) has defined reproductive health as follows:
“Within the framework of WHO’s definition of health as a state of complete
physical, mental, and social well-being, and not merely the absence of disease or
infirmity; reproductive health addresses the reproductive processes, functions
and systems at all stages of life. Reproductive health therefore implies that people
are able to have a responsible, satisfying and safe sex life and that they have the
capability to reproduce and the freedom to decide, if when, and how often to do
so. This definition focus on right of men and women to be informed of and to
have access to safe, effective, affordable, and acceptable methods of fertility
regulation of their choice, and the right to access to appropriate health care services
that will enable women to go safely through pregnancy and childbirth and provide
couples with the best chance of having a healthy infant”.
In order to effectively improve the health status of women and children and fulfil
the unmet need for Family Welfare services in the country, especially the poor
and under-served by reducing infant child and maternal mortality and morbidity,
Government of India during 1997-98 launched the RCH Programme for
implementation during the 9th plan period by integrating Child Survival and Safe
Motherhood (CSSM) Programme with other reproductive and child health (RCH)
services. In addition, a new component for management of Reproductive Tract
22 Infection (RTI) and Sexually Transmitted Infection (STI) was also incorporated.
Essential Components of RCH Programme Current Trends in
Maternal Nursing
1) Prevention and management of unwanted pregnancy.
2) Maternal care that includes antenatal, delivery and postpartum services.
3) Child survival services for new borns and infants.
4) Management of Reproductive Tract Infection (RTIs) and Sexually Transmitted
Infections (STIs).
5) Establishing effective referral system
6) Reproductive services to adolescents.
7) Health services including counselling on sexuality and family life.
Major Elements of RCH Programme
A. Reproductive Health Elements
• Responsible and healthy sexual behaviour
• Interventions to Promote Safe Motherhood
• Essential Obstetric Care for All
• Prevention of Unwanted Pregnancies: Increase Access to Contraceptives
• Emergency Contraceptives
• Safe Abortion
• Pregnancy and Delivery Services
• First Referral Units (FRUs) for Emergency Obstetric Care
• Management of RTIs/STDs
• Infertility & Gynecological Disorders
• Referral facilities by Government /Private Sector for Pregnant Woman
at Risk
• Reproductive Health Services for Adolescent Health
• Global Reproductive Health Strategy
B. Child Survival Element
• Essential New Born Care
• Prevention and Management of Vaccine Preventable Disease
• Urban Measles Campaign
• Elimination of Neonatal Tetanus
• Cold Chain System
• Polio Eradication: Pulse Polio Programmes
• Hepatitis B Vaccine
• MMR Vaccine 23
Nursing Management in • Global Alliance for Vaccine and Immunisation (GAVI)
Maternal Health
• Diarrhoea Control Programme and ORS Programme

• Prevention and Control of Vitamin A deficiency among children

Strategy of RCH phase-I

1) Bottom-up Planning

2) Decentralised Participatory Planning & Implementation

3) Strengthening Infrastructure

4) Integrated Training Package

5) Improved Management

Weaknesses in Reproductive Child Health Programme-I

Some of the identified critical weaknesses in RCH-I were:

1) The so-called paradigm shift in the programme was not backed up with active
promotional efforts or activities.

2) Decentralized community-based programme would need a strong

decentralized planning and implementation process.

3) Being entirely controlled by the Central Government, the States found it

difficult to tailor the project to meet their specific felt needs.

4) There were multiple partners who were supporting independent projects rather
than a cohesive national programme.

5) The involvement of the private sector in the delivery of RCH care was limited.

Reproductive and Child Health Programme-phase II

Phase II of the RCH program aims to:

• Minimize the regional variations in the areas of Reproductive and Child

Health and population stabilization through an integrated, focused,
participatory program and meet the unmet demands of the target population.

• Reduce maternal mortality ratio (MMR), infant mortality rate (IMR), total
fertility rate (TFR), increase couple protection rate and immunization coverage
of children to hundred percent.

• Make provision for common essential package of service delivery

mechanisms.

• Ensure that the supply side strategies are oriented to the demand side
sensitivities to bring about assured, equitable, responsive and quality
service.

• Ensure that the system is geared up to mission mode by using performance

benchmarking and accountability tools.

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• Overcome the regional variations, differential approaches have been adopted Current Trends in
Maternal Nursing
for a group of states at homogenous levels of achievement while designing
the program.
Objectives of RCH Phase II
1) Reduction of Maternal Morbidity and Mortality
2) Reduction of Infant Morbidity and Mortality
3) Reduction of Under 5 Morbidity and Mortality
4) Promotion of Adolescent Health
5) Control of Reproductive Tract Infections and Sexually Transmitted Infections.
Components
 Essential obstetrical care

 Emergency obstetrical care

 Strengthening referral system

 Strengthening project management

 Strengthening infrastructure

 Capacity building

 Improving referral system

 Strengthening MIS

 Innovative schemes

Essential obstetric care

• Promotion of institutional deliveries- 50% of the PHCs and CHCs were made
operational as 24 hours delivery centres.
• Skilled attendance at birth
• Policy decisions to permit ANM to use life-saving drugs carry out certain
interventions in emergency situations to reduce maternal mortality
Emergency obstetric care
• Operationalisation of FRUs (First Referral Units) to provide:24 hours delivery
services: Availability of Services such as 24 hours. Delivery services and
New Born care. Family Planning services, counselling services, availability
of RTI, STI services and Safe abortion services (MVA - Manual Vacum
Aspiration etc.)
• Emergency obstetric care, New born care and emergency care of the sick
child
• Full range of family planning services
• Safe abortion services:
 Medical Method: Termination of early pregnancy (49days) mifepristone
followed by misoprostol 25
Nursing Management in  Manual Vaccum Aspiration Safe and simple technique for termination
Maternal Health
of pregnancy that can be used at PHC or comparable facility.
• Treatment of RTI and STI
• Blood storage facility
• Essential laboratory services
• Referral (transport) services: due to poor utilization of funds and lack of
community participation during RCH-I a community mechanism was
considered to be developed whereby the funds will be placed with AWW /
ANM, JSY. A provision to provide outsource ambulances at PHCs, CHCs,
and FRUs was also made.
New initiatives
• Training of PHC doctors in life saving aesthetic skills for emergency obstetric
care at FRUs is to be conducted. Training of MBBS doctors in collaboration
with FOGSI in obstetric management and skills including caesarean section.
Duration of training to be 16 weeks.
• Setting up of blood storage centers at FRUs
• Janani Suraksha Yojana (JSY): It is safe motherhood intervention, replacing
the “National Maternity Benefit Scheme”, under NRHM. JSY is a 100 %
centrally sponsored scheme to reduce overall Maternal Mortality Ratio and
Infant Mortality Rate. The scheme not only promotes institutional delivery
but also integrates benefit of cash assistance with delivery & post delivery
care. The Accredited Social Health Activist (ASHA) works as a link health
worker between the women and the govt. service providers.
• Vandemataram scheme: It is a voluntary scheme wherein the private doctors
can volunteer themselves for providing safe motherhood services. The
enrolled doctors will display ‘vandemataram logo’ at their clinics. Iron and
folic acid tablets, oral pills, TT injections, etc will be provided by the district
medical officer for free distribution to the beneficiaries. The cases needing
special care can be referred to government hospitals with Vandemataram
Card where they will be provided due care.

1.3.9 Millennium Development Goals (MDGs)

The United Nations Millennium Development Goals are eight goals that all 191
UN member states have agreed to try to achieve by the year 2015. The United
Nations Millennium Declaration, signed in September 2000 commits world
leaders to combat poverty, hunger, disease, illiteracy, environmental degradation,
and discrimination against women. The MDGs are derived from this Declaration,
and all have specific targets and indicators.
The Eight Millennium Development Goals are:
1) to eradicate extreme poverty and hunger
2) to achieve universal primary education; Ensure that, by 2015, children
everywhere, boys and girls alike, will be able to complete a full course of
primary schooling
26
3) to promote gender equality and empower women; Eliminate gender disparity Current Trends in
Maternal Nursing
in primary and secondary education, preferably by 2005, and to all levels of
education no later than 2015
4) to reduce child mortality; Reduce by two-thirds, between 1990 and 2015, the
under-five mortality rate
5) to improve maternal health; Reduce by three quarters, between 1990 and
2015, the maternal mortality ratio
6) to combat HIV/AIDS, malaria, and other diseases; To halt by 2015 and begin
to reverse the spread of HIV/AIDS
7) to ensure environmental sustainability; and
8) to develop a global partnership for development
The MDGs are inter-dependent; all the MDG influence health, and health
influences all the MDGs. For example, better health enables children to learn
and adults to earn. Gender equality is essential to the achievement of better health.
Reducing poverty, hunger and environmental degradation positively influences,
but also depends on, better health.

1.3.10 NATIONAL RURAL HEALTH MISSION (NRHM)/

RCH-II (2005-12)
The NRHM was launched on 12th April 2005 throughout the country by the then
Prime Minister of India, with special focus on 18 States, including 18 EAG states,
the North Eastern States, Jammu & Kashmir and Himachal Pradesh.
The Vision of the Mission
1) To provide effective healthcare to rural population throughout the country
with special focus on 18 states, which have weak public health indicators
and/or weak infrastructure. 18 special focus states are Arunachal Pradesh,
Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and
Kashmir, Manipur , Mizoram, Meghalaya, Madhya Pradesh, Nagaland,
Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
2) To raise public spending on health from 0.9% GDP to 2-3% of GDP, with
improved arrangement for community financing and risk pooling.
3) To undertake architectural correction of the health system to enable it to
effectively handle increased allocations and promote policies that strengthen
public health management and service delivery in the country.
4) To revitalize local health traditions and mainstream AYUSH into the public
health system.
5) Effective integration of health concerns through decentralized management
at district, with determinants of health like sanitation and hygiene, nutrition,
safe drinking water, gender and social concerns.
6) Address inter State and inter district disparities
7) Time bound goals and report publicly on progress.
8) To improve access to rural people, especially poor women and children to
equitable, affordable, accountable and effective primary health care. 27
Nursing Management in The National Rural Health Mission (NRHM) has been launched with a view to
Maternal Health
bringing about dramatic improvement in the health system and the health status
of the people, especially those who live in the rural areas of the country. The
Mission seeks to provide universal access to equitable, affordable and quality
health care which is accountable at the same time responsive to the needs of the
people, reduction of child and maternal deaths as well as population stabilization,
gender and demographic
balance. In this process, the Mission would help achieve goals set under the
National Health Policy and the Millennium Development Goals. To achieve these
goals NRHM will:
• Facilitate increased access and utilization of quality health services by all.
• Forge a partnership between the Central, state and the local governments
• Set up a platform for involving the Panchayati Raj institutions and community
in the management of primary health programmes and infrastructure.
• Provide an opportunity for promoting equity and social justice.
• Establish a mechanism to provide flexibility to the states and the community
to promote local initiatives.
• Develop a framework for promoting inter-sectoral convergence for promotive
and preventive health care.
The Objectives of the Mission
• Reduction in child and maternal mortality
• Universal access to public services for food and nutrition, sanitation and
hygiene and
• universal access to public health care services with emphasis on services
addressing women’s and children’s health and universal immunization
• Prevention and control of communicable and non-communicable diseases,
including locally endemic diseases.
• Access to integrated comprehensive primary health care.
• Population stabilization, gender and demographic balance.
• Revitalize local health traditions & mainstream AYUSH.

• Promotion of healthy life styles.

The expected outcomes from the Mission as reflected in statistical data are:
• IMR reduced to 30/1000 live births by 2012.
• Maternal Mortality reduced to 100/100,000 live births by 2012.
• TFR reduced to 2.1 by 2012.
• Malaria Mortality Reduction Rate - 50% up to 2010, additional 10% by
2012.
28
• Kala Azar Mortality Reduction Rate - 100% by 2010 and sustaining Current Trends in
Maternal Nursing
elimination until 2012.
• Filaria/Microfilaria Reduction Rate - 70% by 2010, 80% by 2012 and
elimination by 2015.
• Dengue Mortality Reduction Rate - 50% by 2010 and sustaining at that level
until 2012.
• Cataract operations-increasing to 46 lakhs until 2012.
• Leprosy Prevalence Rate –reduce from 1.8 per 10,000 in 2005 to less then 1
per 10,000 thereafter.
• Tuberculosis DOTS series - maintain 85% cure rate through entire Mission
Period and also sustain planned case detection rate.
• Upgrading all Community Health Centers to Indian Public Health Standards.
• Increase utilization of First Referral units from bed occupancy by referred
cases of less than 20% to over 75%.
• Engaging 4,00,000 female Accredited Social Health Activists (ASHAs).
The expected outcomes at Community level
• Availability of trained community level worker at village level, with a drug
kit for generic ailments.
• Health Day at Aanganwadi level on a fixed day/month for provision of
immunization, ante/post natal check-ups and services related to mother and
child health care, including nutrition.
• Availability of generic drugs for common ailments at sub Centre and Hospital
level.
• Access to good hospital care through assured availability of doctors, drugs
and quality services at PHC/CHC level and assured referral-transport-
communication systems to reach these facilities in time.
• Improved access to universal immunization through induction of Auto
Disabled Syringes, alternate vaccine delivery and improved mobilization
services under the programme.
• Improved facilities for institutional deliveries through provision of referral
transport, escort and improved hospital care subsidized under the Janani
Surakshya Yojana (JSY) for the below poverty line families.
• Availability of assured health care at reduced financial risk through pilots of
Community Health Insurance under the Mission.
• Availability of safe drinking water.
• Provision of household toilets.
• Improved outreach services to medically under-served remote areas through
mobile medical units.
• Increase awareness about preventive health including nutrition.
29
Nursing Management in The core strategies of the Mission
Maternal Health
• Train and enhance capacity of Panchayati Raj Institutions (PRIs) to own,
control and manage public health services.

• Promote access to improved healthcare at household level through the female

health activist (ASHA).

• Health Plan for each village through Village Health Committee of the
Panchayat. Strengthening sub-centre through better human resource
development, clear quality standards, better community support and an untied
fund to enable local planning and action and more Multi Purpose Workers
(MPWs).
• Strengthening existing (PHCs) through better staffing and human resource
development policy, clear quality standards, better community support and
an untied fund to enable the local management committee to achieve these
standards.
• Provision of 30-50 bedded CHC per lakh population for improved curative
care to a normative standard. (IPHS defining personnel, equipment and
management standards, its decentralized administration by a hospital
management committee and the provision of adequate funds and powers to
enable these committees to reach desired levels)
• Preparation and implementation of an inter sector District Health Plan
prepared by the District Health Mission, including drinking water, sanitation,
hygiene and nutrition Integrating vertical Health and Family Welfare
programmes at National, State, District and Block levels.

• Technical support to National, State and District Health Mission, for public
health management

• Strengthening capacities for data collection, assessment and review for

evidence-based planning, monitoring and supervision.
• Formulation of transparent policies for deployment and career development
of human resource for health.
• Developing capacities for preventive health care at all levels for promoting
healthy life style, reduction in consumption of tobacco and alcohol, etc.
• Promoting non-profit sector particularly in underserved areas.
The supplementary strategies of the mission

• Regulation for Private sector including the informal Rural Medical

Practitioners (RMP) to ensure availability of quality service to citizens at
reasonable cost.
• Promotion of public private partnerships for achieving public health goals.
• Mainstreaming AYUSH – revitalizing local health traditions.

• Reorienting medical education to support rural health issues including

regulation of medical care and medical ethics.
30
• Effective and visible risk pooling and social health insurance to provide health Current Trends in
Maternal Nursing
security to the poor by ensuring accessible, affordable, accountable and good
quality hospital care.
The Special Focus States
While the Mission covers the entire country, it has identified 18 States for special
attention. These states are the ones with weak public health indicators and/or
weak health infrastructure. These are Arunachal Pradesh, Assam, Bihar,
Chhattisgarh, Himachal Pradesh, Jharkhand, Jammu & Kashmir, Manipur,
Mizoram, Meghalaya, Madhya Pradesh, Nagaland, Orissa, Rajasthan, Sikkim,
Tripura, Uttaranchal and Uttar Pradesh. While all the Mission activities are the
same for all the States/UTs in the country, the high focus States would be supported
for having an Accredited Social Health Activist (ASHA) in all villages with a
population of 1000 and also in having Project Management Support at the State
and District level. It also articulated a need for including the health needs of the
urban poor while planning for health through District Health Plans. The Mission
is to be implemented over a period of seven years (2005-2012). The NRHM
District Health Plans will cover District and Sub Divisional/Taluk Hospitals as
well as they cater to rural households as well.
Institutional Mechanisms
• Village Health & Sanitation Samiti (at village level consisting of Panchayat
Representative/s, ANM/MPW, Anganwadi worker, teacher, ASHA,
community health volunteers
• Rogi Kalyan Samiti (or equivalent) for community management of public
hospitals
• District Health Mission, under the leadership of Zila Parishad with District
Health Head as Convener and all relevant departments, NGOs, private
professionals etc represented on it
• State Health Mission, Chaired by Chief Minister and co - chaired by Health
Minister and with the State Health Secretary as Convener- representation of
related departments, NGOs, private professionals etc
• Integration of Departments of Health and Family Welfare, at National and
State level
• National Mission Steering Group chaired by Union Minister for Health &
Family Welfare with Deputy Chairman Planning Commission, Ministers of
Panchayat Raj, Rural Development and Human Resource Development and
public health professionals as members, to provide policy support and
guidance to the Mission
• Empowered Programme Committee chaired by Secretary HFW, to be the
Executive Body of the Mission
• Standing Mentoring Group shall guide and oversee the implementation of
ASHA initiative
• Task Groups for Selected Tasks (time- bound).
31
Nursing Management in
Maternal Health Check Your Progress 3
1) The CSSM programme was launched in the year .......................................
2) Enlist the essential components of RCH-I programme.
................................................................................................................
................................................................................................................
................................................................................................................
3) List the objectives of RCH phase II.
................................................................................................................
................................................................................................................
................................................................................................................
4) State millennium development goals 3,4 and 5.
................................................................................................................
................................................................................................................
................................................................................................................
5) Describe the vision of NRHM.
................................................................................................................
................................................................................................................
................................................................................................................
................................................................................................................

National Health Policy (NHP)

National Health Policy 1983
The NHP was announced by the Government of India in 1983. The motto of the
NHP was ‘Health for All’ by 2000 AD by means of an inclusive primary healthcare
service. The indicators to achieve Health for all were:
1) Reduction of Infant Mortality Rate from 125 to below 60 by 2000
2) Reduction of Maternal Mortality Rate from 4.5 to below 2 by 2000
3) To raise life expectancy at birth from 52.6 to 64
4) To reduce Crude Death Rate from 14 to 9
5) To reduce Crude Birth Rate from 35 to 21
6) To achieve a Net Reproductive Rate of 1
7) To provide portable water to the entire rural population by 2000
The measures taken by the Government in this area have yielded some notable
results, such as eradication of smallpox, and the near eradication of polio, leprosy,
kala azar, and filariasis. The Total Fertility Rate and Infant Mortality Rate have
gone down considerably. The measures taken by the government in the period
32 1951 to 2007 have yielded positive results in some fields which can be can be
measured by many demographic, epidemiological and infrastructural Current Trends in
Maternal Nursing
determinants. However, in many areas the results have not been as desired.
The basic emphasis of NHP was on the development of primary healthcare
infrastructure, involvement of voluntary organisations, availability of necessary
drugs and vaccines, training of personnel, encouraging medical research and its
application to solving the health problem of people, and on bringing about close
coordination between services related to healthcare and activities such nutrition,
drinking water supply and hygiene. The need to bring about drastic improvement
in health and family planning effort was understood. In spite of the significant
development India has made in the field of public health, both morbidity as well
as mortality rates remains high as compared to the countries of the West and
other developed nations. Over the years, the incidence of some of the infectious
diseases like malaria, tuberculosis, HIV/ AIDS, hepatitis and non-communicable
diseases like cancers, lifestyle diseases, diabetes, etc. were on the rise and much
more dedicated efforts were required if we wish to ensure
‘Health for All’. It is therefore time to take stock of the situation and march
ahead with greater zeal. Accordingly, the NHP 1983 was revised and a new,
extensive NHP was enunciated by the Government of India in 2002.
National Health Policy, 2002
Taking into account the advent of new diseases on the scene and the progress
medical science has made since 1983, NHP 2002 was formulated. New targets
were set to eliminate inequity in the system and to correct the regional imbalances.
Steps were taken to strengthen the infrastructure of PHCs throughout the country.
The policy has set certain goals to be achieved by 2015 and to make available for
all sections of society healthcare of acceptable standards.
Main Objectives
1) To achieve and acceptable standard of good health among the general
population of the country
2) The approach would be increase access to decentralize public health system
by establishing new infrastructure in the existing institute
3) Ensure equitable access to health services across the social and geographical
expanse of the country
4) Priority will be given to preventive and first line curative initiatives at primary
health level
5) Focus on those diseases which are principally contributing to disease burden
such a TB, HIV, Malaria, Blindness etc
6) Emphasis will be laid on rational use of drugs within the allopathic system.
Goals
• Eliminate Lymphatic Filariasis -2015
• Eliminate Kala – Azar-2010
• Eliminate malaria and vector and water borne diseases-2010
• Reduce prevalence of blindness to 0.5% 33
Nursing Management in • Reduce IMR to 30/1000 and MMR to 100/1 Lakh by 2010
Maternal Health
• Increase utilization of public health facilities current level of <20 % to >
75 %
• Increase health expenditure by government as a % of GDP from the existing
0.9 % to 2%
• Increase share of central grants to constitute at least 25% of total health
spending
• Further increase to 8 % of the budget
• Achieve zero level growth of HIV/ AIDS-2007
• Eradicate Polio
• Eliminate Leprosy-2005
• Establish an integrated system of surveillance, National health accounts &
Health statistics
• Increase state sector health spending from 5.5 % to 7% of the budget-2005
Strategies of National Health Policy 2002
The strategies adopted by the GOI to achieve the objectives are:
a) Upgrade infrastructure in institutions that are already in existence and establish
new ones in areas which are deficient in healthcare infrastructure.
b) To make across-the-board healthcare available to the entire population without
discrimination throughout India.
c) To increase the Central Government investment in public healthcare
institutions. Also, to make public health administration at the state level more
efficient.
d) To increase the involvement of the private sector in health sector.
e) To give priority to prevention of outbreak of disease. This must be done at
the level of PHCs. First-line curative measures must be strengthened.
f) To rationalise allopathic drug usage To make the time-tested traditional
systems of medicine easily accessible to people. The National Health Policy
acknowledges the need to promote partnership with numerous healthcare
providers in order to make technically better and cheaper healthcare services
available to all.
NHP-2002 therefore made a realistic attempt, taking into account financial
constraints, to broaden the base of healthcare services in India to make it equally
available to all sections of society. It therefore sought to lay new strategies to
speed up the achievement of goals in public healthcare in the situation of the
prevailing socio-economic circumstances in India.
NHP-2002 had certain features in common with the National Population Policy-
2000. These features related to (a) controlling the spread of HIV/AIDS and other
communicable diseases; (b) vaccinating all children to protect them from major
34
preventable diseases; (c) bridging the gaps in reproductive healthcare services; Current Trends in
Maternal Nursing
and (d) strengthening the infrastructure. Any plan to get better the healthcare
standards in the country will have to incorporate the strategies of NPP-2000 and
NHP- 2000.
NHP-2000 recognised the fact that though planning and financing may be done
by the Central Government, implementation of plans and policies has to be done
by the State Governments, NGOs and diverse institutions of the civil society. It
also recognised the importance of population control, clean drinking water,
hygiene, nutrition and prevention of outbreak of epidemics in healthcare.
The National Health Policy, 2017 (NHP, 2017)
The National Health Policy of 1983 and the National Health Policy of 2002 have
served well in guiding the approach for the health sector in the Five-Year Plans.
The current context has however changed in four major ways. First, the health
priorities are changing. Although maternal and child mortality have rapidly
declined, there is growing burden on account of non-communicable diseases and
some infectious diseases. The second important change is the emergence of a
robust health care industry estimated to be growing at double digit. The third
change is the growing incidences of catastrophic expenditure due to health care
costs, which are presently estimated to be one of the major contributors to poverty.
Fourth, a rising economic growth enables enhanced fiscal capacity. Therefore, a
new health policy responsive to these contextual changes is required.
The primary aim of the National Health Policy, 2017, is to inform, clarify,
strengthen and prioritize the role of the Government in shaping health systems in
all its dimensions- investments in health, organization of healthcare services,
prevention of diseases and promotion of good health through cross sectoral actions,
access to technologies, developing human resources, encouraging medical
pluralism, building knowledge base, developing better financial protection
strategies, strengthening regulation and health assurance.
The National Health Policy, 2017 (NHP, 2017) seeks to reach everyone in a
comprehensive integrated way to move towards wellness. It aims at achieving
universal health coverage and delivering quality health care services to all at
affordable cost.
Goal of NHP 17
The policy envisages as its goal the attainment of the highest possible level of
health and well-being for all at all ages, through a preventive and promotive
health care orientation in all developmental policies, and universal access to good
quality health care services without anyone having to face financial hardship as a
consequence. This would be achieved through increasing access, improving
quality and lowering the cost of healthcare delivery.
Key Policy Principles
I. Professionalism, Integrity and Ethics: The health policy commits itself to
the highest professional standards, integrity and ethics to be maintained in
the entire system of health care delivery in the country, supported by a credible,
transparent and responsible regulatory environment.
II. Equity: Reducing inequity would mean affirmative action to reach the
poorest. It would mean minimizing disparity on account of gender, poverty, 35
Nursing Management in caste, disability, other forms of social exclusion and geographical barriers. It
Maternal Health
would imply greater investments and financial protection for the poor who
suffer the largest burden of disease.
III. Affordability: As costs of care increases, affordability, as distinct from equity,
requires emphasis. Catastrophic household health care expenditures defined
as health expenditure exceeding 10% of its total monthly consumption
expenditure or 40% of its monthly non-food consumption expenditure, are
unacceptable.
IV. Universality: Prevention of exclusions on social, economic or on grounds
of current health status. In this backdrop, systems and services are envisaged
to be designed to cater to the entire population- including special groups.
V. Patient Centered & Quality of Care: Gender sensitive, effective, safe, and
convenient healthcare services to be provided with dignity and confidentiality.
There is need to evolve and disseminate standards and guidelines for all
levels of facilities and a system to ensure that the quality of healthcare is not
compromised.
VI. Accountability: Financial and performance accountability, transparency in
decision making, and elimination of corruption in health care systems, both
in public and private.
VII.Inclusive Partnerships: A multi stake holder approach with partnership &
participation of all non-health ministries and communities. This approach
would include partnerships with academic institutions, not for profit agencies,
and health care industry as well.
VIII.Pluralism: Patients who so choose and when appropriate, would have access
to AYUSH care providers based on documented and validated local, home
and community-based practices. These systems, inter alia, would also have
Government support in research and supervision to develop and enrich their
contribution to meeting the national health goals and objectives through
integrative practices.
IX. Decentralization: Decentralisation of decision making to a level as is
consistent with practical considerations and institutional capacity. Community
participation in health planning processes, to be promoted side by side.
X. Dynamism and Adaptiveness: constantly improving dynamic organization
of health care based on new knowledge and evidence with learning from the
communities and from national and international knowledge partners is
designed
Objectives
Improve health status through concerted policy action in all sectors and expand
preventive, promotive, curative, palliative and rehabilitative services provided
through the public health sector with focus on quality.
• Progressively achieve Universal Health Coverage
• Reinforcing trust in Public Health Care System
• Align the growth of private health care sector with public health goals
36
• Specific Quantitative Goals and Objectives: The indicative, quantitative goals Current Trends in
Maternal Nursing
and objectives are outlined under three broad components viz. (a) health
status and programme impact, (b) health systems performance and (c) health
system strengthening. These goals and objectives are aligned to achieve
sustainable development in health sector in keeping with the policy thrust
a. Health Status and Programme Impact
1. Life Expectancy and healthy life
o Increase Life Expectancy at birth from 67.5 to 70 by 2025.
o Establish regular tracking of Disability Adjusted Life Years
(DALY) Index as a measure of burden of disease and its trends
by major categories by 2022.
o Reduction of TFR to 2.1 at national and sub-national level by
2025.
2. Mortality by Age and/ or cause
o Reduce Under Five Mortality to 23 by 2025 and MMR from
current levels to 100 by 2020.
o Reduce infant mortality rate to 28 by 2019.
o Reduce neo-natal mortality to 16 and still birth rate to “single
digit” by 2025.
3. Reduction of disease prevalence/ incidence
o Achieve global target of 2020 which is also termed as target of
90:90:90, for HIV/AIDS i.e, - 90% of all people living with HIV
know their HIV status, - 90% of all people diagnosed with HIV
infection receive sustained antiretroviral therapy and 90% of all
people receiving antiretroviral therapy will have viral
suppression.
o Achieve and maintain elimination status of Leprosy by
2018, Kala-Azar by 2017 and Lymphatic Filariasis in endemic
pockets by 2017.
o To achieve and maintain a cure rate of >85% in new sputum
positive patients for TB and reduce incidence of new cases, to
reach elimination status by 2025.
o To reduce the prevalence of blindness to 0.25/ 1000 by 2025
and disease burden by one third from current levels.
o To reduce premature mortality from cardiovascular diseases,
cancer, diabetes or chronic respiratory diseases by 25% by 2025.
b. Health Systems Performance
1. Coverage of Health Services
o Increase utilization of public health facilities by 50% from current
levels by 2025.
37
Nursing Management in o Antenatal care coverage to be sustained above 90% and skilled
Maternal Health
attendance at birth above 90% by 2025.
o More than 90% of the new born are fully immunized by one
year of age by 2025.
o Meet need of family planning above 90% at national and sub
national level by 2025.
o 80% of known hypertensive and diabetic individuals at
household level maintain “controlled disease status” by 2025.
2. Cross Sectoral goals related to health
o Relative reduction in prevalence of current tobacco use by 15%
by 2020 and 30% by 2025.
o Reduction of 40% in prevalence of stunting of under-five children
by 2025.
o Access to safe water and sanitation to all by 2020 (Swachh Bharat
Mission).
o Reduction of occupational injury by half from current levels of
334 per lakh agricultural workers by 2020.
o National/ State level tracking of selected health behaviour.
c. Health Systems strengthening
1. Health finance
o Increase health expenditure by Government as a percentage of
GDP from the existing 1.1 5 % to 2.5 % by 2025.
o Increase State sector health spending to > 8% of their budget by
2020.
o Decrease in proportion of households facing catastrophic health
expenditure from the current levels by 25%, by 2025.
2. Health Infrastructure and Human Resource
o Ensure availability of paramedics and doctors as per Indian
Public Health Standard (IPHS) norm in high priority districts by
2020.
o Increase community health volunteers to population ratio as per
IPHS norm, in high priority districts by 2025.
o Establish primary and secondary care facility as per norm s in
high priority districts (population as well as time to reach norms)
by 2025.
3. Health Management Information
o Ensure district - level electronic database of information on health
system components by 2020.
o Strengthen the health surveillance system and establish registries
38 for diseases of public health importance by 2020.
 o Establish federated integrated health information architecture, Current Trends in
Maternal Nursing
Health Information Exchanges and National Health Information
Network by 2025.
Policy thrust
1. Ensuring Adequate Investment - The policy proposes a potentially
achievable target of raising public health expenditure to 2.5% of the GDP in
a time bound manner.
2. Preventive and Promotive Health -
The policy articulates to institutionalize inter-sectoral coordination at national
and sub-national levels to optimize health outcomes, through constitution of
bodies that have representation from relevant non-health ministries. This is
in line with the emergent international “Health in All” approach as
complement to Health for All. The policy identifies coordinated action on
seven priority areas for improving the environment for health:
o The Swachh Bharat Abhiyan
o Balanced, healthy diets and regular exercises.
o Addressing tobacco, alcohol and substance abuse

o Yatri Suraksha – preventing deaths due to rail an d road traffic

accidents
o Nirbhaya Nari – action against gender violence

o Reduced stress and improved safety in the work place

o Reducing indoor and outdoor air pollution
3. Organization of Public Health Care Delivery - The policy proposes seven
key policy shifts in organizing health care services.
o In primary care – from selective care to assured comprehensive care
with linkages to referral hospitals
o In secondary and tertiary care – from an input oriented to an output based
strategic purchasing
o In public hospitals – from user fees & cost recovery to assured free drugs,
diagnostic and emergency services to all

o In infrastructure and human resource development – from normative

approach to targeted approach to reach under-serviced areas

o In urban health – from token interventions to on-scale assured

interventions, to organize Primary Health Care delivery and referral
support for urban poor. Collaboration with other sectors to address wider
determinants of urban health is advocated
o In National Health Programmes – integration with health systems for
programme effectiveness and in turn contributing to strengthening of
health systems for efficiency. 39
Nursing Management in o In AYUSH services – from stand-alone to a three dimensional
Maternal Health
mainstreaming
4. Human Resources for Health: There is a need to align decisions regarding
judicious growth of professional and technical educational institutions in the
health sector, ensuring quality of education and regulating the system to
generate the right mix of skills at the right place.
o Medical Education: The policy recommends strengthening existing
medical colleges and converting district hospitals to new medical colleges
to increase number of doctors and specialists
o Attracting and Retaining Doctors in Remote Areas: Policy proposes
financial and non-financial incentives, creating medical colleges in rural
areas; preference to students from under-serviced areas, realigning
pedagogy and curriculum to suit rural health needs
o Specialist Attraction and Retention
o Mid-Level Service Providers: For expansion of primary care from
selective care to comprehensive care, complementary human resource
strategy is the development of a cadre of mid-level care providers. This
can be done through appropriate courses like a B.Sc. in community health
and/or through competency-based bridge courses and short courses. These
bridge courses could admit graduates from different clinical and
paramedical backgrounds like AYUSH doctors, B.Sc. Nurses,
Pharmacists, GNMs, etc and equip them with skills to provide services
at the sub-centre and other peripheral levels.
o Nursing Education: The policy recognises the need to improve
regulation and quality management of nursing education. Other measures
suggested are - establishing cadres like Nurse Practitioners and Public
Health Nurses to increase their availability in most needed areas.
Developing specialized nursing training courses and curriculum (critical
care, cardio-thoracic vascular care, neurological care, trauma care,
palliative care and care of terminally ill), establishing nursing school
in every large district or cluster of districts of about 20 to 30 lakh
population
o ASHA: This policy supports certification programme for ASHAs for
their preferential selection into ANM, nursing and paramedical courses.
While most ASHAs will remain mainly voluntary and remunerated for
time spent, those who obtain qualifications for career opportunities could
be given more regular terms of engagement. Policy also supports enabling
engagements with NGOs to serve as support and training institutions for
ASHAs and to serve as learning laboratories on future roles of community
health workers. The policy recommends revival and strengthening of
Multipurpose Male Health Worker cadre, in order to effectively manage
the emerging infectious and non-communicable diseases at community
level.
o Paramedical Skills: Training courses and curriculum for super specialty
paramedical care (perfusionists, physiotherapists, occupational therapists,
40
 radiological technicians, audiologists, MRI technicians, etc.) would be Current Trends in
Maternal Nursing
developed.

o Public Health Management Cadre: The policy proposes creation of

Public Health Management Cadre in all States based on public health or
related disciplines, as an entry criteria. The policy also advocates an
appropriate career structure and recruitment policy to attract young and
talented multi-disciplinary professionals. Medical & health professionals
would form a major part of this.

o Human Resource Governance and leadership development: The

policy recognizes that human resource management is critical to health
system strengthening and healthcare delivery and therefore the policy
supports measures aimed at continuing medical and nursing education

Historical Background of Family Planning Programme in India

India is the first country to recognize the importance of family planning in the
world. The developments in the family planning programme are:

1877 : It was Dr. Annie Besant, Secretary of Malhusian League, who raised the
issue of population problem and the need to introduce family planning
service before the public.

1912-: Margeret Sanger, a Health Nurse of USA headed the birth control
1923 programme. In 1923, Dr. Stopes popularised birth control movement in
UK.

1925 : Prof. Karve of Bombay started propaganda on birth control.

1930 : Mysore Govt. started the Birth control clinic.

1935 : Indian congress favoured the family planning programme.

1949 : Smt. Rama Rao founded Family Planning Association of India in Bombay.

1951 : Planning Commission started to formulate the comprehensive

programmes to check rapid population growth.

1953 : India became the first country in the world to start birth control
programme and started 147 family planning clinics.

1956 : A Central Family Planning Board was established.

1962 : A Central Family Planning Institute was established during third five
year plan. Local leaders and voluntary organisations were included to
propagate the programme.

1965 : A separate Department of Family Planning was established in Ministry

of Health and Family Planning.

1969 : During fourth five year Plan the Government of India gave “top priority”
to the Family Planning Programme.

1970 : All India Post-Partum programme introduced.

41
Nursing Management in 1972 : Medical Termination of Pregnancy (MTP) Act was passed.
Maternal Health
1977 : Family Planning programme was renamed as Family Welfare
programme.
1978 : India was signatory to Alma Ata declaration.
1983 : Approval of National Health Policy in the Parliament.
1997: Reproductive and child Health Programme-I (RCH-I)
2000 : National Population Policy
2002 : National Health Policy
2005 : National Rural Health Mission and RCH-II
2017 : National Health Policy (NHP 2017)

1.4 ORGANIZATION OF FAMILY WELFARE

PROGRAMME
In India family welfare programme, is a centrally sponsored programme, with
the state govt. & union territories getting 100% assistance from the central govt.
The policy principles are laid down by the centre.
Organisation at National Level: it is shown in Fig. 1.1
At national level the Ministry of Health and Family Welfare is fully responsible
for policy decisions. The Ministry of Health and Family Welfare is answerable to
National Cabinet Committee (Union minister of health and family welfare is the
president of the committee. Central Family Planning Council (consisting of health
ministers of all the states) along with Advisory Councils Board Committee work
in coordination with the Ministry of Health and Family Welfare Dept. Of Family
Welfare. Additional Secretary of the dept. of Family Planning is the overall in-
charge for the implementation of services rendered by Ministry of Health and
Family Welfare. Assistant commissioner and Joint Secretary assist him in
implantation of the programmes. There is a market executive (Mass Media and
Communication) working under direct control of additional secretary. For
technical expertise and advise there is an apex institute i.e., National Institute of
Health and Family Welfare to promote health and family welfare through
education, research, training and evaluation.
At national level the ministry of health is responsible for policy, planning and
decision making related to family welfare programme. The Family Welfare Dept.
has two wings 1. Administrative wing. 2. Technical Wing for implementation of
the programme.
Administrative wing has the following divisions
• Policy Division: Formulates policies
• In charge of Media Division: Looks after the activities of organization
• Aided Programme Division: Aims at improving health care services.
• The Organised sector Division: Coordinates dept. policies
42
• Voluntary Organisation Division: assigns programmes to voluntary agencies Current Trends in
Maternal Nursing
and assess the efficiency of voluntary agencies.
Technical wing is responsible for various activities related to training research
and services e.g. antenatal care, post-natal care, immunization services and
prevention of anaemia and malnutrition etc. The implementation wing helps in
planning, monitoring and evaluation of the programme performance. It coordinates
the demographic research and education. It consists of the following divisions:
• Maternal & Child Health Division
• Evaluation & Intelligence Division
• Technical Operation Division
• Mass education & Media Division
• Nirodh Marketing Division
• Area Project Division

Fig. 1.1 : ORGANIZATION OF FAMILY WELFARE PROGRAMME

AT NATIONAL LEVEL

Organization at state level

The administration of state family welfare programme is the responsibility of
state Government. The programme is organised as three tier system namely state,
district and PHC.
State Cabinet committee: consists of chief minister as chairperson and health
minister, finance and social welfare are the members of state Cabinet Committee.
The committee formulates policies and reviews the progress from time to time.
State Family Planning Council: is an advisory body in relation to formulation
of policy.
The state dept. of health and family welfare and state family welfare bureau:
It is responsible for execution of the programme. The state family welfare bureau
is headed by joint director of health services in-charge.
43
Nursing Management in Action or Implementation Committee: It has state chief secretary as chairman
Maternal Health
with development commissioner health secretary, director of medical services
and regional director for family planning as members. Its role is advisory in
nature. The committee advises on policy formulation and administrative operations
Organization at District level
The District health officer is in-charge of program at district level. District Family
Planning Bureau with district family planning officer as in-charge assists District
health officer. District Family Planning Bureau has three main divisions namely
Administrative Division, Education & information Division, Field Operation &
Evaluation Division.
Organization at block level (Primary Health Centre)
The main unit of family planning at block level is Primary Health Centre. It
provides the services to people to meet their
needs. It provides family planning services, mass communication, information
education and communication.

Check Your Progress 4

1) State the objectives of National Health Policy 2002.

................................................................................................................
................................................................................................................
................................................................................................................

2) Describe key policy principles of NHP 2017.

................................................................................................................
................................................................................................................
................................................................................................................

3) Describe the organization of family welfare programme at national level.

................................................................................................................
................................................................................................................
................................................................................................................

1.5 ROLE OF NURSE IN FAMILY WELFARE

SERVICES
Now we will discuss the role of a nurse in providing the family planning services.
The nurse is expected to give a special attention to the unique need of couple/
parents. You need to counsel them for meeting their need. Now let us see what is
counselling.
“Counselling is a way to help individuals and families understand and cope
with their situation. So they can make decisions and take action for better
44 health.”
As a nurse you have following role to play: Current Trends in
Maternal Nursing
1) Counsellor’s Role
As a nurse you will come across with difficult couples requiring special care
and advises.
You need to clear their doubts and assist them in making decisions for
themselves.
2) Administrative Roles
As a nurse you may be called upon to participate in organisation of Family
Welfare Department at National, Regional and Local level. She may have to
set-up a family welfare clinic and manage the administrative activities.
3) Supervisory Role
Nursing personnel are responsible for practical supervision and in-service
education of their health workers and professionals.
4) Functional Role
As a community health nurse she will be responsible in finding eligible
couples. Help the couples to choose a suitable method of contraception. She
may be asked to run a clinic or assist the doctor for various other activities
related to family planning
5) Educational Role
The main role of a nurse is to educate people about Family Planning. The
health education can be held in the health centres, hospitals, clinics, schools,
homes etc.
6) Role in Research
The nurse should have an enthusiastic mind to answer the questions and find
the solution to it. As a member of the health team she needs to have enough
data to answer such questions. She keeps accurate records to analyze the
facts to help in further planning of the family planning activities in her area
of assignment.

1.6 LET US SUM UP

Nursing has been in existence from the time immemorial. In the initial phase it
was in a very crude form. There was no scientific base for it. But slowly nursing
had been transformed and now it is having a strong scientific basis as well as its
own body of knowledge. In future the maternal nurse may be asked to act as an
advocate of mothers, an expert to manage obstetric and neonatal emergencies.
Her role may be more well defined and demand professional expertise to reduce
maternal and neonatal mortality and morbidity.
In view of the future demand of maternal and child health services the nurse has
a vital role in family welfare services. She needs to be more acquainted with new
methods of contraception to help women to adopt as per her choice. She needs to
be an educator for masses, a good administrator to make the programme a success
and an efficient supervisor.
45
Nursing Management in So the nurse has a great responsibility to play in delivering the family welfare
Maternal Health
services to the people and make it a people’s programme.

1.7 ANSWERS TO CHECK YOUR PROGRESS

Check Your Progress 1
1) a) Midwife
b) 1947
c) Kartar Singh Committee
2) The future of maternity nursing in India is very challenging. She will have to
take up responsibilities for the total care of the pregnant woman and her
child throughout the maternity cycle. She will have to act as an advocate to
the client, educate the community for proper nutrition, safe delivery and the
need for taking care of the mother for a healthy child birth. The nurse midwife
have to develop scientific evidence based knowledge and practice of
midwifery and take part in research activities. As a maternity nurse expert
she may be called upon to manage obstetric and neonatal emergencies.
3) a) Age at marriage
b) Duration of married life
c) Education
d) Economic status
e) Caste and religion
Check Your Progress 2
1) The population problems of India are:
• Environmental Pollution
• Urbanization
• Water Supply
• Food scarcity
• Economic growth
2) The objectives of Population policy 2000 are:
i) To address the unmet needs for basic reproduction (contraception), child
health services, supplies and infrastructure (health personnel).
ii) To make school education up to age 14 free and compulsory and reduce
dropouts at primary and secondary school levels to below 20 per cent for
both boys and girls.
iii) To reduce infant mortality rate to below 30 per 1,000 live births.
iv) To reduce maternal mortality rate to below 100 per 100,000 live births.
v) To achieve universal immunization of children against all vaccine
46 preventable diseases.
3) The strategies of NPP 2000 are: Current Trends in
Maternal Nursing
i) Decentralised Planning and Programme Implementation
ii) Convergence of Service Delivery at Village Levels
iii) Empowering Women for Improved Health and Nutrition
iv) Prioritizing and intensifying measures for child Health and Survival
v) Meeting the Unmet Needs for Family Welfare Services
vi) Special attention on under-Served Population Groups e.g. people living
in slums, tribal population and adolescents
Check Your Progress 3
1) The CSSM programme was launched in 1992.
2) The essential components of RCH-I are:
i) Prevention and management of unwanted pregnancy.
ii) Maternal care that includes antenatal, delivery and postpartum services.
iii) Child survival services for new borns and infants.
iv) Management of Reproductive Tract Infection (TRIs) and Sexually
Transmitted Infections (STIs).
v) Establishing effective referral system
vi) Reproductive services to adolescents.
vii) Health services including counselling on sexuality and family life.
3) The objectives of RCH-II are:
i) Reduction of Maternal Morbidity and Mortality
ii) Reduction of Infant Morbidity and Mortality
iii) Reduction of Under 5 Morbidity and Mortality
iv) Promotion of Adolescent Health
v) Control of Reproductive Tract Infections and Sexually Transmitted
Infections.
4) The millennium development goals 3,4 and 5 are:
i) to promote gender equality and empower women; Eliminate gender
disparity in primary and secondary education, preferably by 2005, and
to all levels of education no later than 2015
ii) to reduce child mortality; Reduce by two-thirds, between 1990 and 2015,
the under-five mortality rate
iii) to improve maternal health; Reduce by three quarters, between 1990
and 2015, the maternal mortality ratio
5) The vision of NRHM is
i) To provide effective healthcare to rural population throughout the country 47
Nursing Management in with special focus on 18 states, which have weak public health indicators
Maternal Health
and/or weak infrastructure. 18 special focus states are Arunachal Pradesh,
Assam, Bihar, Chattisgarh, Himachal Pradesh, Jharkhand, Jammu and
Kashmir, Manipur, Mizoram, Meghalaya, Madhya Pradesh, Nagaland,
Orissa, Rajasthan, Sikkim, Tripura, Uttaranchal and Uttar Pradesh.
ii) To raise public spending on health from 0.9% GDP to 2-3% of GDP,
with improved arrangement for community financing and risk pooling.
iii) To undertake architectural correction of the health system to enable it to
effectively handle increased allocations and promote policies that
strengthen public health management and service delivery in the country.
iv) To revitalize local health traditions and mainstream AYUSH into the
public health system.
v) Effective integration of health concerns through decentralized
management at district, with determinants of health like sanitation and
hygiene, nutrition, safe drinking water, gender and social concerns.
vi) Address inter State and inter district disparities
vii) Time bound goals and report publicly on progress.
viii) To improve access to rural people, especially poor women and children
to equitable, affordable, accountable and effective primary health care.
Check Your Progress 4
1) The objectives of NHP 2002 are:
i) To achieve and acceptable standard of good health among the general
population of the country
ii) The approach would be increase access to decentralize public health
system by establishing new infrastructure in the existing institute
iii) Ensure equitable access to health services across the social and
geographical expanse of the country
iv) Priority will be given to preventive and first line curative initiatives at
primary health level
v) Focus on those diseases which are principally contributing to disease
burden such a TB, HIV, Malaria, Blindness etc
vi) Emphasis will be laid on rational use of drugs within the allopathic system.
2) The key policy principles of NHP 17:
i) Professionalism, Integrity and Ethics
ii) Equity
iii) Affordability
iv) Universality
v) Patient Centered & Quality of Care

48 vi) Accountability
 vii) Inclusive Partnerships Current Trends in
Maternal Nursing
viii)Pluralism
ix) Decentralization.
x) Dynamism and Adaptiveness
3) Organization of family welfare services at national level:
At national level the Ministry of Health and Family Welfare is fully responsible
for policy decisions. The Ministry of Health and Family Welfare is answerable
to National Cabinet Committee (Union minister of health and family welfare
is the president of the committee. Central Family Planning Council (consisting
of health ministers of all the states) along with Advisory Councils Board
Committee work in coordination with the Ministry of Health and Family
Welfare Dept. Of Family Welfare. Additional Secretary of the dept. of Family
Planning is the overall in-charge for the implementation of services rendered
by Ministry of Health and Family Welfare. Assistant commissioner and Joint
Secretary assist him in implantation of the programmes. There is a market
executive (Mass Media and Communication) working under direct control
of additional secretary. For technical expertise and advise there is an apex
institute i.e., National Institute of Health and Family Welfare to promote
health and family welfare through education, research, training and evaluation.
At national level the ministry of health is responsible for policy, planning
and decision making related to family welfare programme. The Family
Welfare Dept. has two wings 1. Administrative wing. 2. Technical Wing for
implementation of the programme.

49