TABLE OF CONTENTS
1.	Terms of Reference and Composition
2.	Report of the Sub-Group on Strategies to Address Unmet Needs for Maternal and Child Health
3.	Recommendations
	Specific Recommendation
	• Training programme for doctors for providing Anaesthesia
	• Operationalizing First Referral units for provision of emergency obstetric care
	• MCH out reach services for all villages
	• AWW for basic maternal & child health care services
	• Development of Cadre of Nurse Midwives in Public and Private Sector
	• Improving the quality of Antenatal care
	• Training programme on MTP services
	• Action for declining of Infant mortality
4.	List of Participants

The National Commission on Population vide their order No. N-11011/25/2000-NCP dated 4th October, 2001 inter-alia constituted a Sub-group on strategies to address unmet needs for maternal and child health under the chairmanship of the Secretary, Department of Family Welfare Government of India. The terms of Reference and composition of the Sub-group was as under:-

Shri A. R. Nanda
Secretary, Deptt. of Family Welfare - Chairman

The final meeting of the sub-group on unmet needs for Maternal and Child Health was held under the Chairmanship of Shri A.R. Nanda, Secretary (FW), on 15.3.2001 at 10.00AM in the Committee Room, Nirman Bhawan, New Delhi.

2. Shri Nanda, Secretary (FW), welcomed the participants and mentioned that the Sub-Group was set up in the wake of the adoption of the National Population Policy-2000 and the decisions taken in the first meeting of the National Commission on Population. First meeting of this Sub-Group was held on December 4, 2000 when it was decided to constitute a small working group for formulating specific proposals for addressing unmet needs, which could then be discussed in the Sub-Group. The Working Group met on 29.1.2001, under the Chairmanship of Shri Gautam Basu, Joint Secretary in Department of Family Welfare to discuss strategies to address unmet needs for maternal and Child health. The Working Group held detailed discussion on various issues related to maternal and child health and evolved a set of recommendations for consideration of the Sub Group, in its next meeting.

3. Shri Gautam Basu, Joint Secretary, briefed that the working Group during its meeting on 29.1.01 had detailed deliberation on unmet needs for Maternal and Child Health. The main issues identified were non availability of para medical staff, development of a cadre of nurse midwives in public and private sectors, improving the quality of antenatal care, training programme for doctors in Anaesthesia, providing 24 hour delivery services at PHCs, training programme and popularization of simpler methods of improving safe abortion services, accelerating decline in Infant and Child Mortality and bringing about convergence among various departments, He informed that the working group had taken into account the significant achievements with regard to infant mortality, institutional and safe delivery rates, couple protection rate and life expectancy at birth. It was felt that there are, however, major regional disparities and critical gaps, which need to be addressed. Focus, therefore, needs to be given to address the gaps in service delivery and also adopt a holistic approach in covering tribal and other underserved areas like urban slums and adolescents. He also highlighted the major inputs provided by the Govt. of India under the RCH programme for improving maternal and child health during 9th Plan period i.e. focus on ante natal care, need to liberalize training course for doctors on anaesthesia making FRUs functional at least at district, sub-district and CHC level during 10th Plan period.

4. While commenting on the recommendations of the Working Group Shri Nanda, Secretary (FW) stated that this group had more or less recommended a community based approach both in terms of provision of services, monitoring of the work and supervision. He mentioned that involving the community in these areas should be encouraged. However, he cautioned that while thinking of Community based health delivery system by community based workers, the past experience of Village Health Guide Scheme should be kept in mind. Therefore, any such scheme if at all, should be formulated in such a manner that earlier problems of Village Health Guide Scheme should not be allowed to re-occur. It is preferable that such an initiative should be area specific and handled by Gram Sabha/Panchayat and any honorarium etc., to be paid to such worker should be handled by the Panchayat and should be performance linked. He also stated that the neighboring countries like Sri Lanka have achieved a lot in terms on safe motherhood by following the community-based approaches. During 10th Plan period, experiences of the models practiced outside India like Sri Lanka, Bangladesh, Indonesia and Malaysia etc., should be kept in view and the feasibility of their applicability in India can be worked out. He requested the participants to have frank discussions on each aspect so that a conclusive decision can be reached.

5. Dr. Abhay Bang made a brief presentation in which he highlighted that out of total infant mortality rate of 70, neo natal mortality accounts for about 40-50 and Acute Respiratory Infection for about 10. Therefore, if action is taken to reduce the neo natal mortality rate, automatically infant mortality rate will also be reduced significantly. In order to reduce the neo natal mortality, there is need to increase outreach of MCH services to every village. He informed in detail about the system of trained community based volunteer used by his organization in the Gadchiroli Project. These volunteers were from the villages and selected with community consent, were given quality training and paid according to their performance. Therefore, in order to expand the outreach of MCH services to each village, village health workers may be selected from the community who can be given 3 months training after which they can deliver the service. They can be paid fixed monthly honorarium and honorarium can be linked with the performance.

6. Dr. Manchanda, DDG (MH), informed that for emergency obstetric care, there are acute shortage of anaesthetists. During the National Consultation held in June 2000, it was recommended by FOGSI and Indian Society of anesthesiologists that doctors working in CHCs can be given short course training for about six months on Anaesthesia to enable them to deal with the requirements of emergency obstetric cases. He welcomed the presence of Dr. Usha Sharma, Principal and Head of Department of Obst. & Gynae, Medical College, Meerut and representative of MCI in the meeting, and requested her that MCI should take urgent action to evolve details of training in the interest of improving emergency obst. care at the FRU/CHC level.

7. Dr. Usha Sharma of MCI stated the matter regarding a short course training of six months on emergency obstetric care for working doctors so that they can render services at FRUs, is under consideration by the MCI. Protocol for such training courses is required to be developed. However, as training will be rendered by the Medical Colleges, it depends on them to accept the suggestion for this type of course.

She also stated that doctors are not available in the rural areas for providing Obstetric and Gynaecology services and suggested that areas where obstetric care is suffering due to shortage of doctors, graduate-nurses may be posted there to take care of obstetric and gynecological care. There is however, a possibility here that the highly trained graduates nurses may also not like to be posted at CHCs and Sub-district hospitals and the problem may still persist. She felt that the possibilities of having a cadre of community midwives should be looked into in consultation with the Nursing Council of India.

8. Mrs. Shashi Chugh, representative from Nursing Council of India stated that Indian Nursing Council is developing a Course for BSc Nursing where extensive training will be given for one and a half year and they will be able to manage emergency obstetric cases. Dr. Bais, DDG (M) in the DGHS has clarified that the proposal does not involve creation of any new posts at CHCs and that the training will be for the existing staff nurses posted at CHCs. It has also been clarified that the scheme is at present being taken up on an experimental basis. Moreover a 2 year duration, performance based curriculum has been developed for training of ANMs and this includes conducting safe delivery.

9. Ms. Bhavna B. Mukhopadhyay, VHA stated that performance in maternal and child health care in some of the States like Uttar Pradesh, Bihar, Rajasthan, and North Eastern States are very poor. She added that for such areas, it might be appropriate to think of a village based health approach involving community leaders for generating awareness in the community. If necessary, partnership between NGO and Public/ Private sector can be developed on non-profitable basis for improvement in service delivery.

10. Dr. Prema Ramachandran, Advisor (Health), Planning Commission, reiterated that the issues regarding maternal and child health are well identified. Efforts have to be made to strengthen and improve the existing health care delivery system from the grass root level. In the beginning, areas having shortage of health functionaries have to be identified. Effort should be made for 24 hours delivery services at PHCs level. At least the sub-divisional and district hospitals should be made operational for providing First level Referral care in all the stales, to take care of emergency obstetric cases. She also felt that at present we need not look at infrastructure addition only but also think of utilizing the existing resources more usefully. The existing working nurses of CHCs can be given advance training on emergency obstetric care so that they can look after the emergency obstetric cases independently in the CHCs where doctors are not available.

11. Dr. Satpathy, Deputy Commissioner (Trg) stated that for sustainability of the scheme of community Health Workers, selection and payment of honorarium to the volunteers should be through Panchayat Raj Institutions. Instead of taking of the scheme in large areas, it is desirable that it can be taken up on pilot basis in the areas having easy approaches and then may be expanded to other areas depending upon the success of the pilot project.

12. Dr. Abhay Bang stated that due to shortage of gynaecologists and anaesthetists most of the FRUs are not in a position to render emergency obstetric care. He suggested that Government may consider to involve private sector for emergency obstetric care at FRU level.

13. Dr. Manchanda DDG(MH) said that most of the FRUs even though equipped with equipments, not becoming functional due to shortage of skilled manpower and non- availability of Blood Bank. He mentioned that after the recent amendments in the Drugs and Cosmetic Act, blood can now be stored at FRUs etc by providing for the minimum requirements as provided by the recent amendments.

14. It was decided that the draft recommendations based on the deliberations may be prepared by the Department of Family welfare and circulated among the members present in the meeting and finalized after obtaining their views. The draft Recommendations were accordingly circulated and the recommendations of the sub-group were made after incorporating the feedback received from the members.

Recommendations

The following areas were unanimously identified as priority areas requiring immediate attention to meet the goals set in the National Population Policy for reduction in maternal and infant mortality rates.

(i) Training programme for doctors for providing Anaesthesia

Shortage of anaesthesists is perhaps the single most important cause for inadequacy of emergency care in government hospitals particularly in rural areas. Even with a remuneration of Rs. 1000 per case under the RCH programme, services of private anaesthesists have not been available to rural hospitals. To overcome the shortage of anaesthetists at FRUs, training course of about six months on anaesthesia for managing emergency obstetric cases for serving doctors may be initiated. During the meeting, it was learnt that the Medical Council of India has already initiated discussions on this issue and that necessary protocols etc. would be developed by them. The training, however, will have to be based in medical colleges and the Department of Family Welfare will have to take up this issue with the medical colleges and concerned States and the Medical Council for its clearances and for making the protocols available.

The sub-group felt that training of anaesthesist alone may not be enough for providing emergency obst. care. It is also imperative that the existing infrastructure and specialist manpower at FRUs/CHCs is looked into critically and reorganized and mismatches between infrastructure and manpower corrected. At the first instance it would be desirable to ensure provision of quality emergency care services at least at the district hospital and sub-district hospital followed by FRUs/CHCs. Thus, developing some FRUs in a district by ensuring that they have the required number of specialists in position or have access to the services of specialists on call would be a preferred option rather than having a number of FRUs which may not be providing full range of services. The information on location of emergency services /FRUs must be made available to all villages in the area so that the population knows where they should reach for getting appropriate emergency care. The provision of emergency care has also to be supported by appropriate referral services from sub-centres to PHCs and from PHCs to the functioning First Referral Units providing emergency services.

At present the workload of ANM has increased substantially with more and more new programmes requiring her involvement. Further, in the North Indian States the ANM has to look after a population segment much larger than the original 5000. The absence of the Male Multipurpose Workers at many places has also added to the ANM's workload. Due to this reason, MCH out reach services are not available in rural villages. In order to ensure MCH outreach services in all villages, various alternatives on the line of Gadchiroli Model may be tested out by implementing operational research projects in some identified areas. Implementation on a larger scale can be taken up after considering the experience and implications of introducing such models in these identified areas.

The Anganwadi Workers working under ICDS should be provided training on basic maternal and child health services so that they can play vital role in primary health care delivery at village level particularly immunization, Vit. A, Oral dehydration, ARI and antenatal care. With proper training they can be an effective partner for the ANM to take care of the health of pregnant women and the newborn child. For a higher degree of motivation for these additional duties, some additional incentives need to be considered.

During the Ninth Plan, in spite of best effort, FRUs could not be made fully functional to handle emergency obstetric care and also complicated child ailments. The vacancies of specialists in CHCs, to the extent of about 47% has also widened this gap. With this background, employment of more trained and skilled nursing personnel at the CHC/ FRU level for taking care of emergencies even in the absence of doctors need to be considered seriously. A training program has been envolved by the Department of Health in consultation with the Nursing Council of India and is being implemented on an experimental basis.

In addition to the specialized training to nurses, it has been recommended that a cadre of community based midwives will have to be developed to take care of the needs of safe motherhood services particularly in remote areas of the country. These midwives could be trained and allowed to practice in the community in the same manner as TBAs/Dais. Training to these midwives could be undertaken at the existing nursing/ ANM training institutions with financial support to the trainees during the course. Details of these courses can be worked out in consultation with State Governments and Nursing Council of India.

The Working Group observed that the continued high maternal mortality rate is source of major concern and need to be addressed immediately. There are many PHCs which are under served and where doctors are not available. To ensure quality of antenatal care rendered by ANM in those PHCs, Doctors from near by CHC should visit thc PHC at least once a week. Some incentives can be given for each visit. There is also a need for skill up-gradation training of PHC, CHC as well as sub-centre personnel in screening of pregnant women, identifying at risk pregnancies and providing appropriate care and arranging referral to appropriate institutions as envisaged under the RCH Programme.

One of the major causes of maternal death is illegal and unsafe abortion. The global experience is that abortions during early pregnancy can be managed quite well with the application of the simple surgical techniques like Manual Vacuum Aspiration (MVA). In India, however, the use of MVA technique has not been made popular in government hospitals so far. However, studies on the suitability of this technique are presently being carried out. During the Tenth Plan steps need to be taken to improve the access to MTP services, simplify procedure for recognition of individuals and institutions for performing MTPs, training of doctors in MTP in electrical/ manual vacuum aspiration as well as in the emerging non-surgical methods. The emphasis should be on improving access to safe and quality abortion services and adequate follow-up with the objective of reducing morbidity and mortality due to unsafe abortion within a short time.

The sub group felt that IMR will be declined successfully if neo natal and perinatal deaths are reduced. For reducing the neo natal mortality, it is necessary to establish the MCH out reach services in all villages by involving community based volunteers at village level. With the aim to upgrade the level of actual coverage of vaccination at least up to 80% in all districts of the country during the 10th Plan period, involvement of NGOs and Panchayat Raj Institutions should be encouraged.

List of Participants in the final meeting of the Sub-Group on Strategy to address unmet need for Maternal and Child Health held on 15.3.2001