III.2.1 : MATERNAL AND CHILD HEALTH

a). RCH Context
Both the RCH programme (1997) and the National Population Policy (2000) place importance on achieving the policy goals of reducing maternal, infant and child mortality and morbidity. Several programmes have been introduced to reduce the Maternal Mortality Ratio (MMR). It is estimated that India accounts for nearly 20 % of maternal deaths. The maternal mortality ratio is defined as the number of maternal death (during pregnancy, child birth, and the purperial period) per 100,000 live births. This situation is due to poor reach of health care delivery network in rural areas.

Infant Mortality Ratio (IMR) refers to the possibility of an infant surviving up to the age of one year. The infant mortality ratio declined in India from 101 per thousand live births during 1978 to 72 in 1998. However, this reduction is not the same in all states. In UP, MP, Orissa, Rajastan, Bihar and some other parts of the country, the IMR continues to range between 80-103 per thousand live births. The Child Mortality rate (CMR) (deaths of children 1-4 years age group per thousand children) has also shown similar uneven decline. Mortality risks are higher among infants born to women under age of 20 and where birth intervals are less than 24 months. Studies show that infant mortality rates are higher in rural areas than in urban areas. IMR declines sharply with increasing education and awareness of the mother.

Gender inequalities hamper access to health services. Even when services are available, the utilization of services can be inadequate. This is due to ignorance or prevalent socio-cultural practices reinforced by the low status of women. Early marriage, childbearing and early motherhood increase the risk of maternal morbidity and mortality and infant mortality. Maternal and child health is also severely affected by repeated pregnancies. Child mortality rates are higher among girls that among boys. Neglect of the girl child’s health is often due to socio-cultural reasons such as son-preference.

Maternal and child health programmes should address such gender biases and inequalities.

b). Coverage
A population of 25-30,000 spread over 30-40 villages and preferably co-terminus with area of a PHC could be covered by the NGO. The NGO will be expected to provide a basic package of MCH services in the area. It will also establish linkage with referral services, especially with basic and comprehensive emergency obstetric care facilities, either in public or in private sector. Adolescent mothers will also be included.

c). Measurable Output
NGO should be able to demonstrate a measurable/describable change in maternal and child (0-6 yrs) health status in the community. Following illustrative indicator/s can be considered at the output level:

d). Strategic Interventions
In order to achieve the outputs, the NGO must identify key strategic intervention areas. A gender perspective must be duly incorporated in its project design and in identifying strategic interventions and activities. NGOs can consider the following strategic interventions.

Access to Quality Ante Natal Care services Institutional deliveries through skilled attendant at delivery Essential neonatal care Access to quality child survival interventions Community Action for safe motherhood and child survival.

If necessary, the NGO must conduct a baseline to assess current MCH needs. This could be done for both preventive and promotive MCH services. If a supportive environment already exists in the community, the NGO should strengthen the same from a MCH perspective. In case the supportive environment is lacking, the NGO should invest in strengthening the same.

The NGO proposing to provide access to MCH services must have the capacity and infrastructure to do so. The NGO must avoid duplication. It must play a complementary role in strengthening the existing health care delivery system for addressing gaps in service delivery. Wherever the existing health care delivery system lacks the capacity, the NGO can identify appropriate referrals, and prepare budgets accordingly.

e) Activities
In each strategic intervention area, the NGO can undertake several different types of activities. The NGO is expected to establish verifiable indicators for each of the strategic intervention areas.

Given is an illustrative list of activities in the strategic intervention areas:

Strategic Intervention Area 1: Access to quality ANC

Strategic Intervention Area 2: Institutional deliveries

Strategic Intervention Area 3: Essential neo-natal care

Strategic Intervention Area 4: Access to quality child survival interventions

Strategic Intervention Area 5: Safe motherhood and child survival

Based on the facilities of undertaking activities, existing health care infrastructure (both in public and private sector), and ICDS, a work plan and budget needs to be prepared.

III.2.2 FAMILY PLANNING SERVICES:

a). RCH Context
Family planning is an important RCH component. The National Family Health Survey II (NFHS) data shows 98% awareness regarding general family planning (male and female sterilization). However, knowledge regarding spacing methods is inadequate and limited. Moreover, the increased awareness has not been matched by increased access to family planning products and services. The NFHS II estimates unmet needs for contraception at around 30%. It indicates that the unmet demand for both limiting and spacing continues to remain high in many states. In rural areas, dependable sources of contraceptive supplies (oral pills, condoms) and follow up care for acceptors are not easily available. Alternative service delivery systems such as commercial, social marketing, and community based distribution system are yet to take roots in rural areas.

An understanding of gender issues in the family planning services is important for effective service provision. Lack of information/services, prevailing myths and misconceptions regarding contraception and care during pregnancy, and poor quality of available family planning services result in unwanted and repeated pregnancies and unsafe abortions.

Male participation in acceptance of temporary or permanent methods is negligible. According to NFHS II data, 34.2% acceptors of family planning methods were for female sterilizations and 1.9% for male sterilizations. There are socio cultural beliefs that influence the choice of methods – for example that men are at the risk of losing their virility if they undergo vasectomy resulting in resistance to use of condoms. The project interventions should place emphasis on bringing attitudinal change among men about temporary and permanent methods of family planning as is in the case of women.

Women contra-indicated for sterilisation, often have few other contraceptive options. For example, sterilised women often cannot insist on condom use by their husbands. They are therefore exposed to the risk of sexually transmitted diseases (STI). Health concerns, limited options, and husband’s opposition are important reasons for non-use. Poor reproductive health and high pregnancy loss lead to limited use of temporary methods. Non-availability of a wide range of reversible methods to suit varying needs can lead to reliance on abortion as a method for spacing births. A significant proportion of unmet need can be met through provision of quality contraceptive services. However, the lack of inter-spousal communication leads to non-use of contraception.

The National Population Policy 2000 recognizes the rights of men and women to be informed and have access to safe, effective, affordable and acceptable methods of family planning of their choice. The number of unintended pregnancies can be reduced through adoption of appropriate family panning methods. This will reduce the number of times a woman is exposed to the risk of child bearing under adverse circumstances. It is important to ensure that family planning products and services are available and accessible to both men and women. This also includes those in the reproductive age group including adolescent boys and girls. Special attention is to be given in areas which are un-served or under served by the existing government health infrastructure.

b). Coverage
Approximately 800-850 eligible couples are expected to live in a sub-centre area and 6000 eligible couples at the PHC level (the number will vary incase of tribal/desert area). The NGO should provide comprehensive Family Planning counseling and contraceptive services and establish linkages with other relevant RCH services. Focus should also be on unmarried young adults.

c). Measurable Output:

The NGO should be able to define outputs that can be measured. The following indicators may be considered.

d). Strategic Interventions
In order to achieve the output/s, the NGO must identify key strategic intervention areas. The NGO must have clarity on what gender issues need to be addressed. It must plan how to address them through selection of appropriate strategies and activities. The following are 3 suggested strategic intervention areas in which the NGO could undertake activities.

If it has not already undertaken, the NGO must conduct a baseline study in order to assess the needs of eligible couples and young adults in terms of knowledge, attitudes, practices and access to FP services. If a supportive environment already exists in the community, the NGO should strengthen the same. The NGO may like to undertake advocacy interventions for informing people about contraceptive choices. The NGO proposing to provide access to FP services must have the capacity and infrastructure to do so.

e). Activities
In each strategic intervention area, the NGO can undertake several different types of activities. Given below is an illustrative list only:

Strategic Intervention Area 1: Demand generation

Strategic Intervention Area 2: Clinic based FP programmes

Strategic Intervention Area 3: Community based distribution of contraceptives

Based on the above, a work plan and a budget plan will be prepared.

III.2.3: ADOLESCENT REPRODUCTIVE HEALTH

a). RCH Context
The RCH Program draws on a life-cycle approach. Adolescent Reproductive Health (ARH) is an important RCH component. In India, nearly 40% of the population comprises of adolescent and young adults. They are in the reproductive age group. Despite being such a significant group, their special needs have not been addressed. Sexual and reproductive decision making by adolescents is affected by factors relating to age and gender. Young boys and girls have poor understanding of pubertal changes and have very little access to counseling and services. Service providers often tend to be judgmental while catering to the needs of adolescents. There are few existing programs providing information on sexual health and sexuality to adolescent girls and boys.

Adolescent girls have little choice on whom and when to marry. They are usually not in a position to negotiate contraceptive use. Almost 75 percent of marriages in rural India among adolescent girls is below the age of 16. The first child is born even before the girl is 18 years of age. Infants born to teenage mothers are at higher risk of low birth weight, pre maturity and still born. Incidence of obstetric complications is also high among the adolescent mothers. Poor personal hygiene, myths and misconceptions about sexual and reproductive health lead to complications in pregnancies and maternal mortality. Often young girls do not get information on physiological implications of menstruation. Instead they are subject to taboos during menstruation such as, isolation, not permitted to cook/or mingle in the family.

The magnitude of adolescent sexual activity is significant. It is higher in boys than girls. Most adolescents seek information from friends and peers on sexual and reproductive issues. These tend to be misleading or inaccurate. Girls are not encouraged to know about their bodies and about reproduction till they are married. However gender norms expect boys to be sexually experienced well before marriage. This results in risky sexual behaviour on the part of many young men. Young people are at a greater risk of contracting sexually transmitted diseases including HIV/AIDS. This is due to early onset of sexual activity, reluctance /ignorance to use preventive methods and frequent partner change.

For unmarried adolescent girls, access to contraception and to MTP is very difficult. This is largely due to social pressures and biases of service providers. This puts unmarried adolescents at risk of unsafe abortions. Girls are not expected to be informed about contraception before marriage. There is pressure to bear the first child immediately after marriage. As a result there is near absence of contraception in the 15-19 age group. This also means that adolescent girls run greater risks related to STIs. Early pregnancy carries with it higher risks of maternal mortality.

In the past, both health and family welfare programs have neglected the adolescent groups. Some interventions focused on married adolescents. It is important to understand age and gender specific reproductive health needs of adolescents. Increase in opportunities for awareness and access to affordable RH products and services will have positive impact on the lives of adolescents and their health status.

b). Coverage
Approximately 750-800 adolescent boys and girls in the age group (10-19 years) are expected to live in a sub-centre area (the number will vary incase of tribal/desert area). The NGO will be expected to provide comprehensive Adolescent Reproductive Health (ARH) education for increasing the knowledge on RH issues (family planning, RTI/STI, personal hygiene, anemia, teenage pregnancy and age at marriage), and services. Focus will be on both in-school and out-of-school, married and unmarried adolescent girls and boys. Interventions could cover mixed or exclusive group.

c). Measurable Output
The NGO should be able to define measurable outputs. It is expected that the NGO should be able to measure progress in terms of

d). Strategic Interventions
In order to achieve the output/s, the NGO must identify key strategic intervention areas. There are differences in the needs and concerns of adolescent girls and boys. The strategies for working with girls would vary from that of working with boys.

Working with mixed groups of girls and boys must be attempted. Invariably, all adolescent interventions must have support of parents and guardians. The NGO must have clarity on what gender issues need to be addressed. It must plan how to address them through selection of appropriate strategies and activities.

The following are 3 suggested strategic intervention areas in which the NGO could undertake activities.

The NGO must conduct a baseline study in order to assess the needs of adolescent girls and boys in terms of knowledge, attitudes, practices and utilisation of services. If a supportive environment already exists in the community, the NGO should strengthen the same from the ARH perspective.

The NGO proposing to provide access to ARH services must have the capacity and infrastructure to do so. ARH is a relatively new aspect. It is therefore important that the NGO networks and links with institutions which have the required experience, both from public and private sources.

e). Activities
In each strategic intervention area, the NGO can undertake several different types of activities. Given below is an illustrative list.

Strategic Intervention Area 1: Supportive Environment

Strategic Intervention Area 2 & 3: Access to services & Life Skills Development

Based on the above, a work plan and a budget plan will be prepared.

III.2.4 PREVENTION AND MANAGMENT OF REPRODUCTIVE TRACT INFECTIONS (RTI)

a). RCH Context
Reproductive Tract Infections (RTI) including Sexually Transmitted Infections (STI) are being recognized as a major problem. This has been brought into the reproductive health agenda. Many RTIs are sexually transmitted. The emergence of HIV and identification of STIs as a facilitating factor for transmission of HIV/AIDS has led to efforts of designing appropriate programmes to address unmet needs for RTIs/STIs.

Young people are at a greater risk of contracting sexually transmitted diseases including HIV/AIDS, due to early onset of sexual activity, reluctance /ignorance to use preventive methods and frequency of partner change. The common causes of RTI among women include infections due to inadequate medical procedures such as un safe abortions, unclean deliveries, and other diagnostics and therapeutic procedures, infections associated with inadequate personal, sexual and menstrual hygiene practices and sexually transmitted infections. Men also experience RTI in the form of uretheritis and genital infections. Though both men and women get infected, the prevalence and the consequences are much more severe for women.

Women hesitate to discuss the issue of RTI since it is related to sexual activity. Untreated RTI/STI create complications resulting from spread of infection to other part of reproductive tract or other organs of the body. Major complications include, infertility, ectopic pregnancy, and cervical cancer resulting in mortality or psychological problems for women. Some infection may cause fetal wastage, pre term delivery, low birth weight babies or infecting the newborn during the delivery.

Treatment of women for STD and RTIs without the cooperation of men is an area of concern in the management of RTIs and STDs. Self-reporting of gynecological problems is low. This is because it is associated with a sense of embarrassment and shame. This affects chances of being diagnosed and treated. Extra marital sex of male partners contributes to the problem. Lack of negotiating ability of women in the practice of unsafe sex by partners also contributes to the problem. Treatment options available to the women are limited by a number of factors. These include a symptomatic nature of these diseases in women, their access to services, non-availability of female doctors, cultural resistance to internal examinations, and lack of availability of non-stigmatizing treatment in public sector. Patients find it easier to use the services offered by unqualified quacks though the quality of service is poor. There is need to increase the availability of quality services to people to meet their unmet needs for the management of RTI.

b). Coverage
A population of 25-30,000 spread over 30-40 villages an