Reproductive Health Package CSR PFI Section VIII Quality of Care RCH :: PFI Publication :: KNOWLEDGE MANAGEMENT CENTRE PORTAL, POPULATION FOUNDATION OF INDIA

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Reproductive Health Package CSR PFI Section VIII Quality of Care RCH

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Reproductive Health Package CSR PFI Section VIII Quality of Care RCH

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Section VIII

Quality of Care in Reproductive and

Child Health Care Services

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Section VIII

QUALITY OF CARE IN REPRODUCTIVE AND

CHILD HEALTH CARE SERVICES

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chapter 21

QUALITY OF CARE IN REPRODUCTIVE AND CHILD

HEALTHCARE SERVICES

In 1998, a team from the World Bank reviewed several Indian studies dealing with problems of

under-utilization of maternal and child healthcare services, that had been planned extensively and at

a high cost. The review concluded that some of the reasons for the under-utilization of available MCH

and family welfare services were:

• Not client-centred

Inadequate information reaching the community regarding services and the lack of choices

available.

Lack of motivation of the medical and paramedical staff.

Lack of access because of distance, non-availability of transport/finance, loss of wages, etc.

Privacy and confidentiality not maintained.

No client interviews/check on the data for feedback and necessary action, leading to

dissatisfaction.

• Not demand-driven nor based on the needs of the community

Services not matching client needs because of non-involvement of the community in the

planning process. No assessment of people’s needs, health and issues affecting it.

No contacts developed with decision-makers in the community, such as schoolteachers,

private doctors, other NGOs

No linkages developed with government staff

Lack of continuity of care

No community-based facilitators

• Lack of High Quality

Lack of technically qualified staff, especially female doctors

Lack of equipment and blood transfusion facilities

Shortage of drugs and supplies

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- - - - - - - - -C-O-R-P-O- R- -A-T-E-S-O-C-I-A-L-R-E-S-P-O- -N-S-IB-I-L-IT-Y- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -

No standard guidelines

No updating of service providers’ skills

Lack of counselling skills

Rude behaviour of staff

Lack of referral facilities

Lack of gender sensitivity

ANM not having plan of action of MCH and family planning services.

After the International Conference on Population and Development held at Cairo in 1994, the

reproductive heath approach has emerged in India as the approach of choice in addressing women’s

health, family planning and reproductive health issues. In this approach, women are no longer

considered as passive mothers whose health is of interest only when they bear children or when they

become eligible for family planning. Gender equality, human rights, increased range and quality of

services, voluntary and informed choice, prevention and control of abuse by programme managers, and

women’s participation in management decision-making have become integral features of this new

approach. Key changes from the earlier approach have been the abolition of contraceptive targets,

adoption of community need assessment approach and the reproductive and child health programme.

However, the quality of care of reproductive health services continues to be poor at many places. In

this context, advocacy assumes a major role. Advocacy may be seen as efforts by women for community

empowerment. Such advocacy has the potential for putting in place joint assessment of community

needs, collaborative planning for health-related interventions as well as setting up forums for monitoring

quality of service.

What Quality of Care Means

The healthcare provider is supposed to provide technically appropriate healthcare to the patient. To

ensure that the patient receives appropriate care the system of healthcare delivery is divided into

specialities and there is supposed to be an engagement of referrals that ensure that the person with

a particular kind of problem reaches a particular practitioner. The provider is supposed to be the expert

and that her/his advice on treatment reflects this expertise. However, at times the treatment from two

doctors with the same professional qualification differs. The doctors use their own judgement about

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- - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - - -Q-U- -A-L-IT-Y- -O-F- -C-A-R-E- -IN- -R- E- P- -R-O-D-U-C- -T-IV-E- -A-N-D- -C-H-I-L-D- H- -E-A-L-T-H-C-A-R-E- -S-E-R-V-I-C-E-S- - - - - - - - -

what they feel is the most appropriate treatment. Who is the better doctor? The one who has a better

bedside manner? Or the one who has a better equipped clinic?

Some definitions of quality of care are given below:

• Quality of care is the degree to which health services for individual and population increase the

likelihood of desired health outcome and are consistent with current professional knowledge.

(Institute of Medicine 1990)

• Quality of care can be defined by the way the clients are treated by the system or the actual

process of care giving and by the focus on the client’s or user’s perspective of services. (Hulli

1994)

• The degree of match between the client point of view of the performance of the services and

service provider’s view determines client satisfaction. (Ishikawa 1985)

• Quality of care is: doing the right thing; doing things right; doing things at the right time; doing

things with right attitude. (Abou-Zahr 1994)

From these different definitions it emerges that the provider’s attitude towards client satisfaction and

perspective, as well as technical appropriateness and the desired health outcomes are important

components of quality. Other important aspects of quality, especially in a community healthcare

setting, are management issues like access, training, and infrastructure.

Ensuring Quality of Care

In the context of family planning, Judith Bruce (1990)

provides a framework to define quality of care. This

incorporates six elements, as follows: (1) choice of

methods; (2) information given to users; (3) technical

competence; (4) interpersonal relations; (5) mechanisms

to encourage continuity; (6) appropriate constellations

of services.

This formulation has been applied to measure the

quality of services for a long time, but in recent years

the increasing focus on client’s perspectives has led to the addition of other components to this

framework. UNFPA has developed a reproductive health quality framework, which includes nine

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elements. Five of them are applicable in all situations; four are specific to the different reproductive

health conditions. This framework includes the client’s participation in management decisions, which

goes well beyond the concept of client-provider interaction. The framework is given below:

Generic Elements (common to all RH services):

1. service environment

2. client-provider interaction

3. informed decision-making

4. integration of services

5. women’s participation in management

Elements specific to each RH service:

1. access to services

2. equipment and supplies

3. professional standards and technical competence

4. continuity of care

This framework implies that the generic elements have to be improved and ensured in all service

environments. Equipment, supplies, technical competence will depend upon the level of service as

well as the reproductive health condition for which services are being provided. Thus, at the sub-centre

the auxiliary nurse midwife will provide a different level of service while at the district hospital the

specialist will provide another. Similarly, the same reproductive health condition (for example, obstructed

labour) will be dealt with differently at the primary health centre (with referral) compared to the

emergency obstetric care centre (with caesarean section).

In the new perspective, deliery of quality care includes 5 Cs, i.e.

Quality Care = 5 Cs

Client based

Correct approach

Careful

Confidential

Compassionate

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Some aspects of this approach may be noted.

• It brings into focus women and children as a high-priority target group and most likely beneficiaries

of services. It is assumed that in doing so, the approach would cover, to a high degree,

conditions of morbidity, mortality and high fertility, which had earlier not received adequate

focused attention in the health services delivery system.

• Instead of service targets being fixed from above, it introduces need-based bottom-up participatory

planning for identifying community health needs. Information on the needs of the community

forms the basis for planning programmes and targets at the sub-centre (SC), primary health centre

(PHC), district and state levels.

• The process of planning helps in estimating the realistic workload of the auxiliary nurse midwife

(ANM), the supply of medicines, vaccines and facilities and also helps in prioritizing the

services.

• This need-based process works as an in-built mechanism for increased utilization of services.

Advanced realistic planning also helps in providing quality care.

• It increases the range of services to be delivered under reproductive and child healthcare by

including hitherto neglected areas of reproductive tract infections and reproductive health of

adolescents.

• Providing quality care is considered to be one of the most important aspects of service delivery.

For this, the approach includes deployment of several technical personnel and provision of

resource facilities to strengthen management capacities of public sector hospitals, CHCs, PHCs

and sub-centres.

• Other items provided in the RCH programme for improving the quality of care are the provision

for improving and updating the skills of service providers at all levels; adequate provision of

drugs, medicines, equipment, physical facilities and kits; ensuring effective and timely referral

and follow-up, availability of midwifery services for 24 hours at the sub-centre, and in difficult

areas, provision of community-managed delivery centres. This is to ensure that every childbirth

is attended to by a person with midwifery skills and that delivery takes place in clean surroundings.

• In the area of family planning, improved quality and quantity of contraceptives are ensured.

Increased opportunities to the client for choosing contraceptives have been provided.

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• The approach focuses on increased male involvement and promotes the use of male contraceptive

methods.

• The approach recognizes the importance of information, education and communication in

disseminating information about family welfare and mother and child healthcare services. The

emphasis of the information, education and communication programme now is to promote

behavioural change through appropriate counselling/interpersonal communication techniques.

• The reproductive and child healthcare approach encourages identification and training of

community-based reproductive and child healthcare facilitators to supplement the health workers’

information, education and communication function. These facilitators would be local community

volunteers who would be able to impart relevant information, taking into account the social

taboos, local beliefs and attitudes of the people.

• The approach encourages panchayat members to undertake social marketing of contraceptives and

to implement selected health interventions in their areas. Communities and Panchayats can play

a crucial role in improving quality, availability and utilization of services. Panchayat members

are expected to monitor the service providers’ attendance, review the availability of drugs and

vaccines and arrange for timely transport of emergencies to the first referral unit (FRU).

• Regular feedback would be gathered to evaluate the quality of services delivered and the clients’

health-seeking behaviour.

To sum up, some of the factors that determine quality of care are:

• Service delivery

promoting informed choice

providing need-based service delivery

providing follow-up care

• Interpersonal communication

health workers having a friendly and cooperative attitude

spending time with a client

caring for client’s privacy and dignity

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• Technical factors

ensuring technical competence of service providers

using good-quality equipment and drugs

maintaining high standards of hygiene

• Social aspects

Gender-sensitive service provision: increasing the role of women in the programme; keeping

clinics open during a time suitable to women; training in gender sensitivity; getting

women’s feedback in monitoring; encouraging involvement of Panchayats, now that 30 per

cent of members are women; and

encouraging male participation

Ten Golden Rules for Healthcare Providers

1. technical competence

2. sincerity and commitment

3. courteousness and politeness

4. non-judgemental attitude

5. good listening skills

6. good counselling skills

7. compassion and empathy

8. availability and accessibility

9. avoidance of negative body language

10. confidentiality.

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Main Target Group for RCH Services

The following are the main target groups in the RCH programme:

• pregnant women and mothers

• infants and children

• eligible couples

• men and women with RTI

• adolescents

Package of Minimum RCH Services for the Target Groups

A. For Pregnant Women and Mothers

• Identification and Registration: Identification and registration of all pregnant women should

be done within twelve weeks.

• Immunization: Pregnant women must be given two doses of tetanus toxoid immunization

at an interval of one month. The last dose must be given at least one month before the

expected date of delivery.

• Prevention and treatment of anaemia: All pregnant women must be provided supplementary

iron in the form of iron-folic acid tablets (large). One tablet is to be taken daily, with

water, starting from the second trimester onwards, for at least 100 days.

• Antenatal Check-ups: Pregnant women must undergo a minimum of three antenatal check-

ups

1st check-up at the time of registration, by twelve weeks of pregnancy

2nd check-up at 32 weeks

3rd check-up at 36 weeks

The check-ups should include route blood examination, including ABO/Rh typing, urine

examination for protein and sugar, blood pressure and weight monitoring and detecting

complications.

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• Promotion of institutional delivery: Complicated pregnancies like twins, women with high blood

pressure, pre-eclampsia, diabetes, etc., must be referred to the nearest referral unit for institutional

delivery.

• Delivery by trained personnel: Deliveries should be conducted in safe and hygienic surroundings.

The ‘5 cleans’ must be followed at the time of delivery.

• Management of obstetric emergencies: Obstetric emergencies should be identified at the earliest

and referred to the first referral unit for management.

• Post-natal check-ups: The mother should be examined at least thrice following delivery – at 24

hours, on the seventh day and again one month after delivery.

• Birth spacing: Spacing of at least three years between successive childbirths must be encouraged

by offering a choice of contraceptive methods.

B. For Infants and Children

• Essential new-born care: The new-born infant should be kept warm to prevent hypothermia.

Checking the new-born infant’s weight and putting it to the mother’s breast is important. New-

borns born with complications should be referred to the nearest neonatal intensive care unit.

New-borns who are premature or have low birth weight should be provided specialized care.

• Exclusive breast-feeding: Exclusive breast-feeding should be promoted during the first six months,

and good weaning practices should be followed from the fourth month onwards.

• Immunization: BCG, polio, DPT and measles vaccines should be administered to the infant as

per the National Immunization Programme Schedule to guard against six killer diseases.

• Vitamin A prophylaxis: Vitamin A drops should be administered to infants and children to

prevent blindness. Five mega-doses should be given to the child.

• Appropriate diarrhoea management: Parents must be informed about the correct management of

diarrhoea and oral rehydration therapy (ORT).

• Appropriate ARI management: Acute respiratory infections (ARI) in children should be detected

early and referred immediately to the nearest health centre.

• Treatment of anaemia: Anaemia should be detected early and iron-folic acid (IFA) tablets should

be given. Severe cases of anaemia should be referred to the nearest referral unit.

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Box 21.1 presents a list of minimum antenatal services.

Box 21.1. Antenatal Services (Minimum set of services)

Components of antenatal check-up

• History taking – menstrual history, post-obstetric history, contraceptive history, history of

the present pregnancy, etc.

• Physical examination: height, weight, blood pressure, anaemia, jaundice, oedema, etc.

• Abdominal examination: height of the uterus, position of the foetal head, foetal heart

sounds, etc.

• Investigations: haemoglobin estimation, urine examination for protein, etc.

Counselling dealing with

• Diet – including fresh green leafy vegetables, avoid alcohol and smoking

• Rest – at least two hours in the afternoon, avoid lifting heavy weights

• Preparation for childbirth

• Danger signs and need for referral

• Information about referral support

• Information about transport-related support

• Information about National Maternity Benefit scheme

• Need for contraception after delivery

Medication

• 100 IFA tablets to be taken one each daily.

• Two doses of tetanus toxoid (TT) to be taken one month apart, the second dose at least

one month before pregnancy.

• Avoid all unnecessary medicines.

Referral in case of danger signs with referral sheet to appropriate referral centres.

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These services to be provided by the multipurpose female health worker either at the sub-centre

or through home visit.

Minimum set of services for home delivery

• History taking – when did the pain start, how frequent and for how long do the pains last.

• Examination: Position of the head of the baby, foetal heartbeat rate.

• Having the mother lie down in a clean place on a clean sheet.

• Internal examination (only by a provider trained to do so) – extent of opening of the cervix,

extent of rounding of cervix.

• Washing hands, removing rings and bangles, using sterile gloves for internal examination.

• Supporting the mother, talking to her gently: allow her to scream.

• Back massage, massage thighs, allow her to squat.

• Use the disposable delivery kit if it is available.

• Cutting the cord after tying it at both sides with a sterile and new blade.

• Tying the cord with boiled pieces of thread.

• Receiving the baby with soft clean clothes.

• Putting the baby immediately to the breast or ask the mother to roll her nipples.

• Waiting for the placenta to separate and then gently nudge it out without pulling hard or

pressing the abdomen.

• Check the placenta to see whether it is complete.

• Check the abdomen whether the uterus is firmly contracted.

• Immediate referral in case of any danger.

What should not be done

• Do not give injection to speed up labour.

• Do not apply pressure to the abdomen.

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• Do not put anything in the vagina.

• Do not scold or hit the mother.

• Do not pull out the baby.

• Do not apply pressure on the abdomen to pull out the placenta.

Post-natal Services

The multipurpose health worker female has to visit all the women who have had a childbirth

as soon as she comes to know of it within the first week. She has to make three visits in the

first six weeks. The services she is supposed to provide include history-taking and examination.

• History taking:

Date, time and place of birth

The professional medical status of the birth attendant and whether the disposable

delivery pack was used

Any problem faced by the mother after delivery

Bleeding, fever and urination.

The infant’s state of health, feeding habits

• Examine:

Mother: Temperature, breast, position of uterus, genital area.

Baby: Check for congenital abnormalities, weight of baby, note weight in a card.

Counselling

• Immunization for the infant, inform the family of the next date for immunization

• Breast-feeding and diet

• Sex and contraception

• Referral in case of any complication.

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C. For Couples Eligible for Family Planning

• Promotion of contraception: Couples

eligible for family planning should be given

a choice of spacing and permanent methods

to choose from.

• MTP (Medical Termination of Pregnancy):

Safe services for medical termination of

pregnancies should be ensured to women

desiring abortion.

• Follow-up of acceptors: Those who have accepted terminal or spacing methods should be

followed up from time to time to identify complications. Follow-up care should be

provided to the acceptors to ensure continuity of use and user satisfaction.

Boxes 21.2 and 21.3 present a list of quality of care parameters for female sterilization and MTP,

respectively.

Box 21.2. Quality of Care Parameter – Female Sterilization Operation

Eligibility/Counselling/Informed Consent

• Client must be married; male client should ideally be below 60 and female client between

22 years to 45 years; number of children is not a necessary criterion.

• Client must be informed of all available family planning methods.

• Client must make an informed decision for sterilizations voluntarily.

• Client must understand the full implications of sterilization.

• Client must be counselled in the language they understand and they should be made to

understand what will happen before, during and after the surgery, its side-effects or potential

complications.

• Consent should not be obtained under physical or mental stress.

• There should be a separate counselling room which offers privacy and ensures avoidance

of any interruptions.

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Standards for Female Sterilization

• Laparoscopic sterilization can be performed only by either a gynaecologist with DGO/MD/

MS or a surgeon with MS degree and trained in laparoscopy.

• A careful clinical assessment of the clients should be made to ensure fitness. In certain

conditions which require the doctors to be cautious, delay surgery, refer or counsel the

patient for alternatives.

• Clinical assessments must include detailed medical history, physical examination, laboratory

examinations which include Hb estimation, urine analysis for sugar and albumin and other

tests, if necessary.

• The operating surgeon must verify eligibility, informed consent, and confirmed fitness.

• Sterilization with MTP is not to be done in camp conditions.

• Pre-medication must be given at least thirty minutes before if given intra-muscularly.

• Local anaesthetic is to be infiltrated on the operation theatre table.

• Medical records are to be maintained related to vital signs.

• Pre-, intra- and post-operative monitoring is to be done with pulse, respiration and blood

pressure records every 15 minutes; and in case of post-operative monitoring, up to one

hour.

• In laparoscopy the patient must not be elevated in excess of 15 degrees. In case of

vasovagal attack she must be immediately made horizontal.

• Slow insufflations and gradual desufflation and peumoperitoneum should be done with air

and preferably with carbon dioxide with pressure not exceeding 20 mm or one litre.

• Communication must be maintained with the client throughout the procedures.

• Discharge is to be done after at least four hours. The client must be provided with a

discharge card with detailed instructions provided in the local language.

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Physical Requirements – Operations Facility

• The facility shall have concrete or tile floor and must have running water, have electricity

supply with generator facility.

• There must be separate space for reception and registration, waiting area, counselling room,

pre-operative waiting area for clients, pre-operating room for part preparation and changing

of client clothes into operation theatre clothes and conducting laboratory tests, hand-

washing area, operation theatre, post-operative recovery room/ward.

• The operation theatre must be isolated and fitted with fly-proof netting. It should be large

for free movement, and be easy to enter and leave, it must have adequate light and lock

when not in use.

• Pre-operative assessment is extremely important in mobile settings and final selection must

be done by the operating surgeon.

• Mobile sterilization services should be offered in places which have an operation theatre.

In no circumstances sterilization should be conducted in a school building or a Panchayat

Bhawan.

• No clinical training should be conducted during any mobile sterilization programme.

• Mobile sterilization services should be conducted preferably between 11.00 and 3.00 in

the daytime. The optimum number of cases to be operated by one team in a day is 20.

• All staff of the mobile team must be skilled in emergency resuscitation measures.

• Necessary emergency equipment must be available in a mobile sterilization service.

• Facility must exist to transfer the client to a higher centre to handle an emergency.

• MTP should not be performed during mobile services.

Prevention of Infection Asepsis and Antisepsis

• The client history of cuts and wounds in the month preceding surgery should be evaluated.

Clients should preferably be dressed in theatre clothes; if not feasible, in clean clothes.

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• All personnel must change into theatre clothes. Movement in the operation theatre should

be minimal. Ideally the surgeon and her/his assistants should scrub thoroughly between

each procedure. If not feasible, do a three-minute scrub or alcoholic glycerine rub every

hour or after five cases.

• After preparation the operative side should be covered by a surgical drape.

• The gloves should be changed after every case.

• All used instruments should be decontaminated, cleaned and properly sterilized.

• Laparoscopes must be wiped with an alcohol-soaked cloth after use, dissembled, washed,

put in a basin of cidex for 20 minutes and rinsed twice with sterile water to remove all

traces of disinfectant.

Proper waste disposal includes burying or burning waste. Burning is preferred. Burning should

be done in an incinerator or closed drum. Waste should not be burnt in the open or left in an

open pit.

Box 21.3. Quality of Care Parameter – Medical Termination of Pregnancy

(from MTP Act, 1971)

When pregnancies may be terminated by registered medical practitioners –

(a) Where the length of the pregnancy does not exceed twelve weeks if such medical practitioner

is, or

(b) Where the length of the pregnancy exceeds twelve weeks but does not exceed twenty

weeks, if not less than two registered medical practitioners are of opinion, formed in good

faith, that –

(i) the continuance of the pregnancy would involve a risk to the life of the pregnant

woman or of grave injury to her physical or mental health; or

(ii) there is a substantial risk that if the child were born, it would suffer from such

physical or mental abnormalities as to be seriously handicapped.

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Explanation 1 – Where any pregnancy is alleged by the pregnant woman to have been caused

by rape, the anguish caused by such pregnancy shall be presumed to constitute a grave injury

to the mental health of the pregnant woman.

Explanation 2 – Where any pregnancy occurs as a result of failure of any device or method used

by any married woman or her husband for the purpose of limiting the number of children, the

anguish caused by such unwanted pregnancy may be resumed to constitute a grave injury to the

mental health of the pregnant woman.

(3) In determining whether the continuance of a pregnancy would involve such risk of injury

to the health as is mentioned in sub-section (2), account may be taken of the pregnant

woman’s actual or reasonable foreseeable environment.

(4) (a) No pregnancy of a woman, who has not attained the age of eighteen years, or, who,

having attained the age of eighteen years, is a lunatic, shall be terminated except with

the consent in writing of her guardian.

(b) Save as otherwise provided in clause (a), no pregnancy shall be terminated except

with the consent of the pregnant woman.

4. Place where pregnancy may be terminated – No termination of pregnancy shall be made

in accordance with this Act at any place other than —

(a) a hospital established or maintained by Government, or

(b) a place for the time being approved for the purpose of this Act by Government.

(1) The provisions of section 4, and so much of the provisions of sub-section (2)

of section 3 as relate to the length of the pregnancy and the opinion of not less

than two registered medical practitioners, shall not apply to the termination of

a pregnancy by a registered medical practitioner in a case where he is of

opinion, formed in good faith, that the termination of such pregnancy is

immediately necessary to save the life of the pregnant woman.

(2) Notwithstanding anything contained in the Indian Penal Code (45 of 1860), the

termination of a pregnancy by a person who is not a registered medical practitioner

shall be an offence punishable under that Code, and that Code shall, to this

extent, stand modified.

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D. For Management of RTI /STIs

• A large number of people, particularly women, suffer from reproductive tract infections

(RTIs) and sexually transmitted infections (STIs). RTIs/STIs, if untreated, may lead to several

complications, including infertility. RTI/STI in a pregnant woman can affect the growth

of the child. People suffering from RTI/STI should be identified and referred to the nearest

health centre to prevent abortions and congenital malformations.

• Raise awareness of RTIs/STIs: The focus should be on information and counselling to raise

awareness of RTIs/STIs. It should be the responsibility of all recognized service providers

to disseminate wider information on RTIs/STIs to help early detection and treatment.

• Management of RTIs/STIs: Early treatment of RTIs/STIs would prevent complications. Patients

should be referred to the nearest specialized health facilty for early detection and treatment.

• Treatment of Infertility: Cases of primary or secondary infertility must be sent to the nearest

specialized health unit for treatment.

E. For Adolescents

Adolescents are the parents of tomorrow. It is important to prepare them for the future by informing

and counselling them on family life and reproductive health, gender sensitization, motherhood skills,

etc.

It is important to realize that no single package can be appropriate for all the states, districts and

communities. Variations in the needs of the people and in the performance of service units are very

common. It is, therefore, necessary that the minimum service packages, discussed earlier, are tailored

according to the needs of specific communities and capacity of service-providing units.

A composite and comprehensive way of looking at quality of care is to consider the factors at three

points in time – (i) upstream at systems (structures and capacities); (ii) at the time of client-provider

interactions (procedures and performance); and beyond, at (iii) outcomes. Table 21.1 presents these

in a nutshell.

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3.1 Page 21

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Table 21.1. Quality of Care Parameters

Quality of Structure/Capacity

Process/Performance

Outcome

• Policy intentions

• Programme design

• Laws, regulation and licensing

• Training of providers and

competence

• Protocol and standards

• Service infrastructure and access

• Management Information Service

• Supply and logistics

• Client participation in

management

• Diagnostics and therapeutic •

appropriateness

•

• Timeliness of care

•

• Integration

• Continuity of care

•

• Interpersonal aspect

• Involving clients in

decision-making

•

• Attending to client comfort – •

decision-making, cleanliness,

privacy, confidentiality

• Special provision for women

and their needs

Therapeutic outcome

Unintended outcomes

Client awareness and

knowledge

Fulfilment of client

expectations

Client satisfaction

Client behaviour

Opportunity for feedback

References

http://www.unfpa.org

Brice, 1990. “Fundamental Elements of the Quality of Case : A Simple Framework”. Studies in Family

Planning 21:61-91.

Das, Abhijit, 2004. “Ensuring Quality of Care in Reproductive Health : An Advocacy Handbook”.

New Delhi, PFI.

Family Planning Division, Ministry of Health and Family Welfare, Government of India, December

2007. “IUCD Reference Manual for Nursing Personnel”.

Family Planning Division, Ministry of Health and Family Welfare, Government of India, December

2007. “IUCD Reference Manual for Medical Officers”.

Population Foundation of India, September 1999. “Training Module: Reproductive and Child Health”.

3.2 Page 22

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Research Studies and Standards Division, Ministry of Health and Family Welfare, Government of

India, October 2006. “Quality Assurance Manual for Sterlization Services”.

Research Studies & Standards Division, Ministry of Health and Family Welfare, Government of India.

October 2006. “Standards for Female and Male Sterilization Services”.

Universal Law Co. Pvt. Ltd. 2003. “The Medical Termination of Pregnancy Act, 1971”.

WHO, Geneva. Integrated Management of Pregnancy and Childbirth (IMPAC), 2000. “Managing

Complications in Pregnancy and Childbirth : A Guide for Midwives and Doctors”.

3.3 Page 23

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