Introduction to Midwifery and Obstetrical NursingCHAPTER 1

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

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

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

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

Hence, the practice of nursing means the performance for compensation of professional service requiring substantial specialised knowledge of the biological, physical, behavioural, psychological, and sociological sciences and of nursing theory as the basis for assessment diagnosis, planning, intervention and evaluation in the promotion and maintenance of health; the case finding and management of illness, injury or infirmity; the restoration of optimum functions or the achievement of a dignified death. Nursing practice includes, but it is not limited to administration, teaching, counselling, supervision, delegation and evaluation of practice and execution of the medical regiment including the administration of medications and treatments prescribed by any person authorised by state law to prescribe. Each registered nurse is directly accountable and responsible to the consumer for quality of nursing care rendered.

According to Florence Nightingale ‘a nurse means any person in charge of the personal health of another. Nursing ought to assist the reparative process; for nightingale believed that all diseases at some period or other of its course, is more or less a reparative process”, and that the symptoms or the sufferings generally considered to be inevitable and incidental to the disease are very often not symptoms of the disease at all but of something quite different- of the want of fresh air, light, warmth, quiet, cleanliness, punctuality and care in the administration of diet, of each of or all of these. She further states that the word “Nursing” has been limited to signify little more than the administration of medicines and the application of policies. It ought to signify the proper use of fresh air, light, warmth, cleanliness, quiet, and the proper selection and administration of diet— all at the least expense of vital power to the patient. Accordingly what nursing has to do is to put the patient in the best condition for nature to act upon him/her.

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

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

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

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

‘Midwife’ means “with woman” or in France, “wise woman.” Throughout the ages, women have depended upon a skilled person, usually another woman, to be with them during childbirth. Now-a-days, in response to women seeking alternatives to physician-hospital services, there has been rebirth of the ‘lay midwife (traditional midwife), the empirically trained midwife. She is usually a mother who learned by apprenticing to another who lay midwife and is responding primarily to women who seek to give birth at home. Unlike “granny midwife” of old, today's lay midwife is usually middle class, well educated, articulate, and wellpaid for her services. As she gained experience and confidence, she questions the need for prerequisite of nursing by these new midwives. They allege that nursing education promulgates the medical model of pregnancy as an illness and birth as a medical event. They further allege that nursing education teaches subservience to medical doctrine even when the doctrine is not supported by scientific research.

The views of individual nurse midwives are divided and the profession has avoided taking a stand on whether it is essential to be a nurse before becoming a midwife. However, most agree that if not a prerequisite, the inclusion of aspects of nursing education are desirable. The expanded opportunities for practice are creating an increased demand to educate nurse-midwives. It is clear that professionals trained exclusively in medical institutions experience discomfort practising in the maternity homes (birth centres) setting. Therefore, if nurse-midwives are to be the primary care providers for childbearing families and birth centres a place for practice of midwifery, a new approach to the education and training of nurse-midwife is called for. Maybe, realizing these views, in India, Midwifery course replaced by two years Auxiliary-Nurse Midwifery course (Now Female Health Worker Training course) and sick nurse training replaced by three and half years General Nursing and Midwifery course. In addition, four years BSc Nursing course curricula included the major components of Midwifery, Obstetrics and Gynaecological nursing. And there is such speciality in Master degree in Nursing and Doctoral degree in Nursing.

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

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

The activities of nurse-midwives includes:

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

New nurses are attracted to and stay in positions that enable them to practise in their desired nursing speciality. About half of them cited the ability to practise their speciality as the primary source of their satisfaction, and almost one-third cited it as the reason for selecting their current position. Most nurses work in hospital settings. Hospitals vary widely in size, services offered, and geographic location. In general, nurses in hospital, work with patients who have medical or surgical conditions, with children, with women and their newborn, with cancer patient, with people who have had severe traumas (injuries) or burns in operating rooms or emergency rooms, and in many other capacities. In addition to direct patient care roles, nurses in hospitals serve as educators, managers, and administrators, who teach or supervise others and establish the directions of nursing hospitalwise.

Obstetrical nursing is one of the specialised area in nursing which focuses on women and their infants and families during the child bearing cycle. It deals with women's health nursing, and reproductive health nursing. Brief description of these terminology are as follows:

Obstetrical nursing focuses on the case of child-bearing and their families through all stages of pregnancy and childbirth and during first-six weeks after birth. Throughout the prenatal period, nurses and nurse-midwives provide care for women in clinics, and health centres and teach classes to help families to prepare for childbirth. They also care for childbearing families during labour and birth in hospitals, birth centres (maternity homes) and less frequently the home. Nurses with special training may provide intensive care for high-risk neonates in special care units and high-risk mothers in antepartum units, in critical care obstetric units, or at home. Maternity nurses teach about pregnancy, the process of labour, birth and recovery, and parenting skills. Investment in health promotion during child 5bearing can make a significant differences in the health of women and their infants.

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

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

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

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

Maternal and child health care which is now also being described as “Reproductive and Child Health” is a very important component of the family welfare programme in India. Reproductive and Child Health (RCH) can be defined as a state in which “people have the ability to reproduce and regulate their fertility; women are able to go through the pregnancy and child birth safely, the outcome of pregnancy is successful in terms of maternal and infant survival and well-being, and couples are able to have sexual relations free of the fear of pregnancy and contracting disease. This means that every couple should be able to have child when they want and that the pregnancy, the mother and the child are safe and well, and contraceptives by choice are available to prevent pregnancy and of contracting disease.” The need for and underlying principles of reproductive health as an approach to solve the population issues were duly highlighted and agreed upon by participating countries during the International conference on “Population and Development” held in Cairo in 1994. In agreement to this decision, the 6Govt of India has formally launched the Reproductive and Child Health (RCH) programme on October 15, 1997.

RCH Programme has envisaged a major shift in certain components, approach and emphasis of the already existing Family Welfare Programme in India. Major focus in this programme is delivery of need based client centred, good quality, comprehensive reproductive and child health services to all the beneficiaries in an integrated manner. In India, the RCH services are to be delivered through the existing primary health care infrastructure with necessary referral and supervisory support from the secondary and teritary level institutions. Capacity building among the personnel involved in the delivery of RCH services through in-service training, is considered as an essential prerequisite for the successful implementation of the programme. Strengthening of task performance skills for delivery of RCH service is particularly felt as required. Accordingly integrated skill development training of primary health care personnel being organised, in which they are trained in these components in an integrated manner throughout the country. The staff nurses placed at primary health centres and community health centres are also covered under this integrated skill training.

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

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

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

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

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

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

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

In practice, mother and child must be considered as one unit. It is because:

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

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

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

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

And there is direct correlation between the illiteracy and fertility, and between infant and maternal mortality, and the age at marriage is well established by demographic studies. While on the other hand, government will pursue its policy to the improvements of women's education level, both through formal and nonformal channels according high priority. It will also bring legislation for raising the minimum age of marriage for girls to 18 and for boys to 21 years.” This has been done through Child Marriage Restraint Act 1978.

The joint conference of Central Councils of Health and Central Family Welfare Council at its meeting held in April 1979, among other things have resolved that” as a part of the package of family welfare, we have to mount gigantic efforts to radically reduce infant and child mortality to at least 50 per cent of the present levels in the shortest possible time. This calls for not only much more expanded immunisation and prophylaxis against nutritional deficiency diseases but also efforts to combat major causes of such mortality namely diarrhoeal and respiratory diseases and malnutrition.

Alma-Ata Declaration on Primary Health Care (1978) stated “that primary health care includes at least education concerning prevailing health problems and the methods of prevailing and controlling them; promotion of food supply and proper nutrition; adequate supply of safe water and basic sanitation; maternal and child health care, including family planning; immunisation against major infectious diseases; prevention and control of total endemic diseases; appropriate treatment of common diseases and injury and provision of essential drugs.”

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

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

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

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

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

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

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

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

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

The policy guidelines for implementation of MCH programme are:

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

The package of services under CSSM Programme are:

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

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

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

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

The basic elements of Reproduction and Child Health Programme are:

The major factors affecting RCH are as follows:

An extrinsic factor affecting RCH care service is the following:

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

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

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

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

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

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

ICDS scheme is designed both as a preventive and development effort. The objectives of the ICDS scheme are:

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

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

Dietary survey in the low socio-economic groups have shown a dietary deficit of 500 to 600 calories in women, and 1000 to 1100 calories in pregnant and lactating mothers. This maternal malnutrition leads to “Low birth weight” babies. The average birth weight of newborn in the lower socio-economic groups 2.7 kg as compared with 3.1 kg in higher socio-economic groups. Low birth weight babies have a worse mortality experience, being more vulnearable to infection. Malnutritions directly or indirectly responsible for over 50 per cent die of severe protein calorie malnutrition every year. And 50 per cent pregnant women in the third trimester have a haemoglobin level of less than 10 grams per cent, anaemia in pregnancy is directly responsible for 20 per cent of all maternal deaths, and indirectly for 20 per cent of all maternal deaths, and indirectly for a much larges proportion. Over 60 per cent of children under 6 years of age suffer from some form of nutritional anaemia and PEM. Vitamin A deficiency is responsible for at least 25,000 children becoming blind every year. About 40 millions people are estimated to be affected by goitre in India.

In view of the high prevalence of malnutrition in India, the Government has launched several nutritious programmes at the national level. The following are the major nutrition programmes that are being implemented in India:

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

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

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

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

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

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

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

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

The objectives of the programme is to providing food to meet the gap in nutritional requirements particularly in poor children. This would help the children, not only improving the nutritional status, but also improve their performance at school. It would indirectly act as an incentive for sending children to school.

In this programme, each primary school child is given food for 200 days. This is to be an addition to what the home provides. This programme is co-ordinated and implemented by the Ministry of Education.

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

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

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

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

The main objectives of the programme are:

The main components of the ANP are:

The programme is coordinated by the Ministry of Rural Reconstruction.

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

The activities of the Applied Nutrition Programme will include:

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