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TRDC Training Module Reproductive and Child Health |
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Training M du
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Training & Resource Development Center
..I.T..I.T..I. POPULATION FOUNDATION OF INDIA
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Preface
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In 1970, a group of enlightened industrialists and population experts led by
Mr. I.R.D. Tata set up Population Foundation·ofIndia(formerly known as
Family Planning Foundation). They firmly believed that a movement of
social development such as Family Planning' should not and can not remain
the sole concern of the government,' and it ought to be supported and
supplemented in planning and implementation by strong, capable and
committed groups of voluntary- organization (VOINGOs) representing
peoples' organised efforts towards promoting the goal of family welfare
and population stablisation.
One of the latest efforts of the Foundation concerns development of human
resource ofNGOs- especially in the newer paradigm of reproductive and
child health. Periodical training is essential to update and upgrade worker's
knowledge and skills. There is a special need for training ~ow so thatNGOs
workers fully comprehend the-concepts and principles of the new RCH
approach and develop skills to implement RCH Programmes. To meet this
need, Foundation is currently implementing a project "Training Resource
Development Centre" to help frontline and middle level NGOs workers,
with financial support from the Department of Family Welfare, Ministry of
Health & Family Welfare, Government of India.
The PFI sincerely hopes that the enclosed training. modules would equip
NGOs with better skills and understanding that will get reflected in their
future activities.
Dr. K. Srinivasan
Executive Director
PFI
September, 1999
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000000000000000000000000000000000000000000
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Acknowledgement
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g g oo The Population
Foundation
of India has received
generous' help and
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guidance from experts and institutions in formulating and implementing
g g o the project "Training and Resource Development Centre" (TRDC), devoted 0
to training.NGO personnel working in Delhi slums. The Foundation takes
o this opportunity to express its grateful thanks to all of them.
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In developing the
valuable materials
training
from a
modules, the PFI has
number of documents,
compiled
modules
and adopted
and teaching
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0
manuals already developed by several well known organisations and
g g' o institutions working in the fields of health, population and social 0
development. The first set of modules developed were reviewed by a panel
o of experienced professionals in the related fields, at the time of pretesting. 0
g g The modules presented here were finalised drawing upon their valuable
ooo
comments and suggestions. We express our grateful thanks to each one of
them for providing greater insight to improve upon the modules.
0
0
0
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0
g g oo The in-house faculty of the Population Foundation of India undertook the
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main responsibility of developing and finalising to modules. The hard work
o put in by them and their sense of involvement are greatly appreciated.
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The PFI
Chatterji,
also gratefully acknowledges
who critically edited the
the contribution of Mr. Asim
script of the modules and of
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Dr. A. S. Sachan for Hindi translation of the modules.
g g o
0
Grateful thanks are also due to Mr. R.R. Subramanian, Ms. Geeta Malhotra,
g g OMs. L.R. Menon, Ms. Veena Gopal, Ms. R. Vanja, Ms. Manju Sharma, 0
Mr. Hans Raj and others in the Foundation who provided administrative
g and secretarial support to help bring-out the modules.
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Introduction
In the recent past, the country has tried several strategies and programmes like Family
Planning, Universal Immurization Programme (UIP), Oral Rehydration Therapy (ORT),
Child Survival and Safe Motherhood (CSSM) etc., to improve substantially the scope
and quality of maternal and child health and achieve population stabilisation at the earliest.
In 1994, during the International Conference on Population and Development (ICPD) in
Cairo, the Indian experiences were widely shared and substantiated by several other
developing countries. The varied Indian experiences were considered and recognised
while developing the concept of "Reproductive and Child Health'" (RCH) for achieving
improved maternal and child health and population stabilisation within a shorter span of
time in a more sustainable manner. The RCH concept and approach which have been
discussed in detail later in the modules got global acceptance for policy formulation and
programme implementation.
The RCH programme has a special significance for India. The RCH approach, which
includes family planning in its wider context extends to promotion of women's status,
gender equity and reproductive rights to counter the existing situation. The RCH
programme is much larger in range and scope than the conventional family welfare
programme, as it seeks to improve the health standard of individual family members and
through it the overall health standard of a community. The desire to limit family size is
to be instinctively felt by every individual in the interest of healthy living under this approach.
These concepts and the strategies and services for a meaningful RCH programme have
been deliberated upon in detail in the modules prepared for the training programme,
keeping in mind the special requirements ofNGO workers. There are 10 modules included
in the training programme, each of which deals with one topic / issue in detail.
These ten modules cover (1) Delhi Slums (2) Role of NGOs in RCH programme
(3) Reproductive System and Reproductive Health (4) ReiJroductiveand Child Health
Services (5) Population and Planned Parenthood (6) Delivery ofRCH Services and Quality
of Care (7) Role of IEC in RCH Programme (8) Project Formulation (9) Project
Implementation Monitoring and Evaluation and (l0) Financial Management.
The contents and format of each module have been designed to promote participative
training. Some of the modules give the basic scientific and technical information to
equip a worker with sound basic knowledge. Some others are on the methodology of
delivery of services which serves to convey the underlying messages of the RCH
programme. Special attention has been paid to communication and counselling. The
modules are expected to come handy in planning, designing, conducting and evaluating
RCH programmes and to act as a practical guide to the NGO workers.
Our expectation is that the modules will be useful to the trainees :
• To enhance their basic knowledge
• To clear doubts
• To learn skills to teach others
• To answer questions of clients
• To remind oneself of important points and procedures
• To be used as a teaching aid
We wish the experience of learning through these modules becomes enjoyable to
NGO workers.
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Module Writers
Dr. K. Srinivasan .
Mr. K.S. Natrajan '
Mr. Ajay Sunder
Dr. Amita Bardhan
Dr. Arundhati Mishra
Dr. Deepti Arora
Mr. H.P. Nagpal
Mr. Samkhothong Haokip
Dr. Sanjay Kumar
Ms. Sunita Arora
Mr. S. Ramaseshan
Dr. Shuchi Gaba
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DELHI SLUMS
@= Learning Objectives
• Identify the roles and responsibilities of both government and Non Governmental
Organisations in improving the overall living conditions of the slum population
• Analyze the efforts of Government and Non Governmenatal Organizations and
assess the strength and weakness of the existing health care infrastructure
~ Teaching Aids
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Reproductive & Child Health Care
Introduction
Delhi is dotted with slums which consist of huts made up of inferior quality material, constructed
in an unplanned manner and closely clustered, and lacking basic amenities like piped water,
sewage connection and electricity. Although the living conditions are inhuman in slums, they
provide easy accommodation to poor migrants who cannot afford better housing. Slums emerge
on the marginal lands, near. the work place of inhabitants, closer to the roads and source of
water. In Delhi itself, an estimated of32 *1 lakh people continue to live in subhuman conditions.
They do not have access to many of the basic necessities of life. This despite the fact that they
live amid an ocean of plenty and prosperity.
What is a Slum ?
UNESCO, defined slum as a building or a group of buildings or an area characterized by
overcrowding, deterioration, unhealthy living conditions or anyone of them that endanger the
health, safety and morals of the inhabitants or the community.
"The slums are residential areas that are physically and socially deteriorated and in which
satisfactory family life is impossible. Bad housing is a major index of slum conditions. By bad
housing is meant dwellings that have inadequate light, air, toilet and bathing facilities; that are
in bad repair, damp and improperly heated; that do not have any room for family privacy; that
are subjected to fire hazard and that overcrowd the land, leaving no space for recreational
use". In other words a slum is a highly congested area marked by deteriorated unsanitary
buildings, property and social disorganization. Due to varying socio-economic conditions and
the character of the city, the definition of slum varies from place to place
In India, slum areas have been defined under section 3 of the Slum Areas
(Improvement and Clearance) Act, 1956,as areas where:
(b) are by reason of dilapidation, over-crowding, fal:llty arrangement and design of such
buildings, narrowness or faulty arrangements of streets, lack of ventilation, light
sanitation facilities or any combination of these factors, are detrimental to safety,
health or morals. And also
/7he figure is on lower side, other books like, f\\ Tale of Two Cities' indicated 65 lakh people living in slums
and sub-standard area.
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2. "In determining whether a building is unfit for human habitation for the purpose of this
Act, the regard shall be had to its conditions in respect of the repair, stability, freedom
from damp, natural light and air, water supply, drainage and sanitary conveniences and
facilities for storage, preparation and cooking of food and for the disposal of waste, and
the buildings shall be deemed to be unfit as aforesaid, if and only if, it is so far defective in
one or more of the said matters that it is not suitable for occupation in that condition.
More appropriately, a slum can be defined as an area of over crowded and dilapidated, usually
old housing, occupied by people who can afford only the cheap dwellings available in the
urban area, generally in or close to the inner city. The term usually implies both a poverty-
ridden population and unhealthy environment and a district rife with crime and vice.
Growth of Slums in Delhi
The slum has come to be accepted as a living reality, an inevitable phenomenon, accompanying
urban growth in all metropolitan cities. Delhi has the third largest slum population in the
country. According to the 1991 census, some of the slums in Delhi have a population density
of more than 60,000 persons per square k.m. According to Sulabh International, about 34.2%
i.e. 32 lakhs*3 of Delhi's population live in slums .. Delhi started witnessing squatting on a
significant scale from 1960 onwards. With continuing increase in urban population and endless
inflow of rural immigrants into the city, slum population is growing at a rate higher than the
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Reproductive & Child Health Care
urban population growth. This increase in slum population (55% per annum) is posing a
serious threat not only to their own health, hygiene and environment but also to those of other
urban areas of their neighbourhood.
The growth of slums in Delhi and other metropolitan cities in the country are a fallout of rapid
population growth during the last four decades and lack of political will in tackling the problem
at its root. Illiteracy and absence of employment opportunities in rural areas compelled tens
and thousands of people to migrate to cities and towns in search of job to eke out a living. The
growth of slums in Delhi corresponds to its increasing pace of urbanization. Slums are the
consequence of poverty and socio-economic backwardness. Thus, they are a by-product of
industrialization and rapid urbanisation.
This is a major cause for concern as slum-dwellers not only form a significant proportion of
the'total urban population, but also playa significant role in urban economy. Providing cheap
labour for construction work, selling green vegetables to the health conscious urban citizens,
pulling rickshaws and providing cheap domestic help are some of the major economic functions
performed by the slum-dwellers.
Factors Associated with the Emergence of Slums
The industrial and overall economic development in the city has created employment
opportunities, and has stimulated large scale in migration into Delhi resulting in rapid population
growth. The choice of site for squatting depends upon a number of factors, such as the
availability of vacant land and water resources, proximity to roads and work place, risk of
evacuation and so on.
Some of the factors which are responsible for the formation and growth of slums in the city of
Delhi are:
• Natural increase in population,
• Poverty,
• Economic Development of City,
• Inadequate Housing,
• Absence of Planning, and
• Political Reasons.
• Natural Increase in Population
The National Capital Territory of Delhi has unfortunately, and perhaps undeservedly,
come to symbolize population growth more than any other city in the world. It had a
population of only fourlakh in 1901, which increased to 94.211akh in 1991 *4. Natural
4* India 1991 •.Population Data Sheet, Registrar General and Census Commission, India, 2A, Man Singh Road,
New Delhi.
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increase in birth rate is one of the main contributing factors of population growth,
followed by rural urban migration.
• Pcverty
Extreme poverty, hunger and unemployment in a region leads to influx of agricultural
labourers into the city. Unable to pay the house rent prevailing in the city, they squat
on every open space available near their work places. Approximately three lakh*5
fresh migrants come into Delhi, every year in search of gainful employment.
• Economic Development of City
Being the capital of the country, Delhi has many attractions for migrants. The setting
up of many private sector undertakings and a large number of medium and small
scale industries, during the last three decades, has had gravitational pull for the mass
influx of skilled, semi-skilled labourers in the city from adjoining districts. A
substantial number of migrants to Delhi belong to distant places.
The urban malaise of shelterlessness and man's efforts to solve it in the most adverse
circumstances of poverty and illiteracy are seen in its most concrete form in slums,
shanty-towns, shack-towns and squatter colonies. Since the industries do not provide
housing facilities to their employees, the low income workers squat on the land
surrounding the vicinity of these industries.
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• Bad Planning
Cities in India have been growing haphazardly with no provision to accommodate the
ever-growing volume of in-migrants. There has also been no viable effort to develop
the employment potential of smaller cities and towns thereby making them unattracti ve
to migrants who leave the countryside.
Politics also playa part in encouraging slums sometimes, but that is outside the purview
of this module.
Type and Distribution of Slums
1. Legally Notified Slum Areas
2. Jhuggi-Jhompri Clusters (JJ Clusters)
3. Unauthorized / Illegal Settlements and Harijan Bastis
4. Urban Villages
5. Pavement Dwellers and
In Delhi, about 65 lakh*6 persons live in sub-standard areas and conditions with hardly any
basic amenities such as electricity, water, latrines or a sewage system.
General Conditions of Slums
Slums are the indicators of poor planning and management of the cities. The image of slums
which one formulates after visiting any of the big cities is that of a clumsy shanty town where
huts are packed densely in a disorderly and haphazard manner and the winding rows of
tenements are separated by narrow alleys. Invariably, they are located at the edge of a storm-
water drain and do not have adequate basic amenities like water, toilets and electricity. Slums
have bestowed Delhi the dubious distinction of being the filthiest among the Metropolitan
cities in the country and also amongst the three most polluted cities in the world alongwith
Cairo and Mexico city*7
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Lack of drainage facilities gives an ugly look to the slums, where waste water from huts get
stagnated in the open in the form of small pools. It emanates a foul smell and leaves little space
6*Source:NHFS ( 1992-93)
7*Ali, Sabir & Singh, S.N. Major Problems of Delhi Slums. Published by Uppal Publishing House. New Delhi. 1998
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for people to walk around. Slums are inhabited by the poorest people who are at the bottom of
the socioeconomic scale and lead a disgruntled life in the burgeoning cities. Old tin and asbestos
sheets, bits of tarpaulin, polythene sheets, gunny bags and dead wood are widely used for the
construction of huts, which are erected on the waste or unused land in the peripheral areas of
big cities. The unhygienic environment created by filth, debris, and pools of stinking water is
hostile to human life. Sometimes, slums emerge near the dumping grounds of city waste,
which escalates the level of pollution in the already vitiated atmosphere. There is little open
space left for the residents to breathe fresh air or for children to play.
A large number of slum -
dwellers in Delhi depend
upon shallow handpump
water which in most cases
is contaminated. According
to an estimate, the entire
Delhi population (94.21
lakh) requires about 535
million gallons of water
daily ( MOD), however the
actual availability is
restricted to 425 MOD after
deducting the operational
losses. The shortfall of 110
MOD is unequally
distributed between the
posh colonies, which have
no shortage even for watering their lawns, and the slum dwellers, who have to strive hard for
survival. A survey by the Delhi based National Institute of Communicable Diseases found
that 50 % of water supplied to 1080 slums is not fit for drinking.
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Majority of the slum dwellers are exposed to water-borne diseases, children and women are
susceptible to such diseases. Another major hazard of slum life is the lack of systems of disposal
of excreta, water from washing and bathing and solid wastes. In particular, the disposal of
human waste is a major environmental and health hazard. Children and women continue to be
the main sufferers in all this. The nutritional level of children living in slums is deplorable.
According to the National Commission on Urbanisation, 85% of children below six years of
age living in urban slums in India are malnourished. Lack of medical facilities further
aggravates their plight. There are not enough trained doctors and para-medical staff to look
after the patients in the slums. They are unable to pay the hefty fee charged by the private
practitioners and nursing homes. All this takes a heavy toll on the health and lives of slum-
dwellers. Added to this is the problem of scarcity due to poverty, inadequate schooling facilities
for children, no privacy for women and poor supply of electricity. The overall situation of
sanitation in Delhi is alarming.
Slums are also turning into mini-training centres ofpick-pocketting and beggary. Gambling
and prostitution are not uncommon. For hard-core criminals slums are a safe refuge. All this
pollutes the social climate of the slums.
The problems of the slum dwellers are manifold. Firstly, they live in sub-human conditions.
Additionally, the degraded environments in which they live take their toll on the physical,
mental and moral health of the slum-dwellers.
Support to Slums
Refuting the western views that consider slums as nurturing pockets of crime, vice and evil,
Laquian (1969)*8, described them as the homes of a unified, intimate and comfortable
community. Their strong bonds are attributed to their common backgrounds. Since most of the
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slum dwellers are migrants from rural to urban areas, who have moved to the city with little or
no skill, low education and meager income, they have to stay in the slums or squat on some
body's land. The same is found to be true with the slums of Delhi.
Several organizations support slums and plead for their regularisation and provision of basic
amenities in them. They empathise with the slum dwellers who are unable to procure better
housing because of its exorbitant price. Several social workers help residents in their uplift and
exert pressures on the government agencies to recognize their existence. Political parties also
work for the slum dwellers though in their own interest, and try to win their confidence in the
bargain creating vote banks for themselves.
These political parties exert pressure on the Municipal Corporation to provide slum-dwellers
with basic amenities. With their efforts only, many slums have been regularized. Many of the
slum-dwellers now have photo identity cards and ration cards, which ensure them greater
security and stability. They now resist the demolition squads and also exert pressures on the
authorities to provide educational and health facilities.
Existing Programmes for Slum Development
Initially, the general policy of the Government of India was to clear unauthorized occupation
of land by demolishing the slums. But demolition of squatter settlements without adequate
remedial measures, was no solution to the housing problem of the urban poor. This policy did
not succeed, as the problem was massive, and even after repeated demolitions the slums upsurged
again. Another hurdle in the programme was the provision of alternative housing which the
government was unable to provide because of lack of funds.
In 1970, the policy was changed from clearance to tolerance and the Slum Improvement
Programme (SIP) was launched which was aimed at providing basic civic amenities such as
water, toilets, drainage, roads, lights and so on to the slum- dwellers. Due to paucity of funds,
the programme did not even touch many of the slums.
In another similar scheme, private builders were encouraged to develop the slums and replace
them with multistoried buildings. After providing a dwelling unit to each hutment owner of
the slum, they were free to sell the remaining flats in the market and recover the cost of
construction and gain some profit as well. However, some of the slum-dwellers resisted this
scheme, as they felt that the builders wanted to pocket the lion's share by giving the former
minimum benefits in the form of smaller flats located inconveniently.
Another feature of this programme was that the slum dwellers could get a loan for the repair of
their huts. Thus low interest loans were given, to be repaid in easy installments spread over 15
years. Government has also constructed VishramgrahslRain Baseras for providing shelters to
absolutely shelterless.
On the basis of the 1976 census, photopasses were issued to all those slum-dwellers who were
registered with the Municipal Corporation. In 1993, Delhi Municipal Corporation again issued
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Reproductive & Child Health Care
photopasses to all those slum-dwellers whose name appeared in the 1985 voter list. These
photopasses entitle the slum dwellers to get an alternative place if the land is required by the
Government for some other purpose and their huts are to be demolished.
Under Environment Improvement in Jhuggi Clusters, Barat Ghars, reading room-cum-libraries,
anganwaries, dispensaries, vyaymshalas, parks, and tot-lots and the Pay and Use Jansuvidha
Complexes are being provided. The Jansuvidha Complexes are being maintained through
nominated agencies like Sulabh International, Institute of Low Cost Sanitation and All India
Pariwar Kalyan Parishad. There are about 300*9 Pay and Use Jansuvidha Complexes operating
in Delhi. Urban Basic Service Programme ( UBSP), was promulgated by the central government
during VII th plan ( 1985-90 ). The scheme contemplated provision of "Pay and Use Jan
Suvidha Complexes". The outbreak of a cholera epidemic in slums and squatters of Delhi in
1988 prompted a more vigorous implementation of the scheme. The UBSP aimed at providing
the following services :
1 Water supply - one tapfor 150 people.
2. Sewer - open drains with normal outflow, avoiding accumulation of
waste water.
3. Storm water drains - to quickly drain out storm water.
4. Community baths - one bath for 20 to 50 people.
6 Widening and paving of existing lanes to avoid mud and slush.
7 Street light - one pole for every 30 meters.
8. Balwadis/Angawadis - one for 25 children in the age group 3-5
The other activities under the programme are provision of community facilities, such as a
community centre and retail shops for beneficiaries, garbage disposal, and maintenance of
slums.
The Delhi Government has recently allocated Rs 1,000 crores under the current National
Slum Development policy, which is three times the last year's allocation of Rs. 335 crores.
It is not that the Government is unaware of the magnitude of slum problems. It has taken
various policy measures for the last several years to improve them. While reviewing/ assessing
these measures, it has been observed that these measures are grossly inadequate in improving
the living conditions of the slum - dwellers as well as in resolving the vicious problems of
slums, resulting in an unhealthy development of Delhi.
The recent UBSP laid emphasis on certain basic social issues like child care, health, nutrition
and basic sanitation. UBSP did recognise social development and behavioural changes as
important criteria for the physical improvement of the settlements .
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Suggestions
While the problems faced by Indian Slums are serious in nature, their solutions pose a greater
challenge. It requires committed efforts form the Government and Non-Governmental agencies.
The government must come up with an integrated policy for eradicating the problems of the
slums. It should incorporate long-term planning for urban housing, decongestion of urban
industrial pockets, resettlement of industrial units to satellite areas, incentives for out-migration,
basic facilities of housing and hygiene to the slum - dwellers and programmes which could
instill a community feeling and project slums as integral part of society.
The Non-Governmental-Organisations can play an equally important role by increasing
awareness about and contributing to health, literacy, nourishment and education to children.
Efforts should also be made to ensure active participation of the slum-dwellers in the various
schemes being run for them. It must be ensured that funds released for various programmess
are utilised properly and schemes are implemented in right earnest.
• The list of the slums should be updated and all areas which do not qualify as a slum
should be deleted from the list of slums. While doing so, the difference between a slum
and squatter should be kept in mind, as the two categories face different kinds of
problems and require different types of solutions.
• In all existing slums the basic amenities for human needs should be provided under the
UBSP scheme.
• For overall development of human resources, greater importance should be attached to
children in these areas. Health, education, sports, and recreational facilities should be
provided to them within the slums or at a reasonable distance, as the poor slum children
cannot afford to go out to longer distances where the current facilities exist. Even if
they venture to go out there, they are discriminated against by the better-offs.
• Many of the slums are located on low lying areas and are inundated during the rainy
season or high tides in the creek. Measures should be taken to raise their levels, connect
them with proper approach roads and concretise the lanes and alleys in order to avoid
the problems of flooding and sludging in soch slums.
• Industrialists and other employers should be involved in providing housing facilities
to all their employees. Tax benefits and other concessions given to them for this
humanitarian work will act as a great motivation and help in solving the housing problem.
• All the existing slums located in dangerous areas should be shifted to safer places.
• The cooperative group housing society scheme should be continued and strengthened,
and more slum-dwellers and builders should be encouraged to participate in this scheme.
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• Activities, which help in the social and cultural assimilation of slum dwellers, should
be taken up. Non-Governmental-Organisations (NGOs) can playa major role in devising
ways of narrowing the gap.
• To control squatting, there should be vigilant groups to inform the authorities of any
unlawful grabbing of land. Immediate action is recommended to remove the encroachers
to avoid the proliferation of slums in the city.
Let us sum Up
As opposed to attractive and healthy places, there are some areas of noise, confusion, dirt, ill-
health, tension and congestion. These areas of confusion and their problems are negative in
character. Such areas of extreme negative character are called slums. Owing to unplanned
development of most Indian cities, innumerable slums are found. The people inhabiting the
slums of several Indian cities are denied even the basic gifts of nature, i.e., air and light.
In the process of industrialization, human beings became a forgotten element. Work.ers were
accommodated somehow and somewhere: houses were 'often placed within the left-over spaces
between the factories and sheds and railroad yards', and land filled in with ashes and broken
glasses and rubbish ...
It is needless to say that the rooms they live in are overcrowded, filthy, and unfit for human
habitation in a civilized society and the slum area is usually associated with some degree of
degradation. Alcoholism, criminality, juvenile delinquency and such other elements of urban
pathology.
Experience has also shown that for slum-dwellers there are more urgent needs than good housing.
One is employment, and most of the opportunities for skilled and semi-skilled labour are
available in the city. Another is money. But there is no quick or sudden solution to the problem.
The remedies have to be carefully planned and they require close co-ordination among several
departments of government, municipality and Non- Governmental-Oragnisations.
The atmosphere of tension and conflict is getting worse day by day as the urban poor do not
find any change in their living conditions. Slums are growing in numbers spreading like
white- ants
Attempts are necessary to develop local community feeling and to prepare citizens to become
aware of their civic responsibilities. They should be made to participate in self-help mutua! aid
programmes and consider such actions with a sense of pride.
Above all, we need to shun the many stereotypes about slum and slum- dwellers. They should
be recognised as fellow human beings with all the rights to dignified life.
It is a pity that even 50 years of the country's freedom have not provided freednm to a large
chunk of our population who continue to live in a bondage of drudgery and deprivation. Pandit
Nehru once observed that slum - dwellers "represent the utmost form of human degradation"
Shockingly, it is true even today .
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Questions
5. What are the most common prevalent diseases there in slums of Delhi due to which
people suffer most?
6. Who is responsibile for upliftment of slums?
Notes:
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Reproductive & Child Health Care
APPENDICES
DELHI AT A GLANCE
Population (ODD's) As on 1st March, 1999
Area (Sq.Km.)
Density (persons per Sq.Km) 1999
Sex Ratio (Females / 1000 males), 1991
Crude Birth Rate, 1997
Crude Death Rate, 1997
Infant Mortality Rate
Literacy Rate, 1991
Persons
Males
-
Females
13,418
1,483
9,048
830
21.1
5.4
35
76.09
82.63
68.01
POPULA TION AND DENSITY OF VARIOUS ZONES
Area
(Sq.KM.)
Population
Percentage
Increase
Density
(Per Sq.KM.)
1981
1991 1981-1991 1981
1991
Delhi Municipal
614.52 5,409,998 8,038,608
48.59 13,547 16,643
Corporation (Urban)
Delhi Municipal
782.77
452,206
943,392
108.62
578
1,183
Corporation (Rural)
NDMC
42.74
273,036
294,149
7.73
6,388
6,882
Cantonment Area
42.97
85,166
94,326
10.76
1,982
2,195
Total
1,483.00 6,220,406 9,370,475
50.64
4,194
6,319
Source: 1) Bureau of Economics and Statistics, Delhi Administration, Delhi
Source: 2) Civic Guide. Municipal Corporation of Delhi.
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Causes of health problems
Vehicle pollution
Noise pollution
Industrial pollution
Very high incidence of Castro enteritis, Respiratory infections, Typhoid, Cholera,
Diarrhoea, Jaundice, Tuberculosis, Bronchitis, Asthma & Scabies.
* See pa~
EXISTING SHORTFALLS UNDER VARIOUS
SERVICES IN DELHI- 1993
I Water
Existing capacity of Water Supply (in million gallons a day)
Present Requirement at the norms of 70 gallons per capita a day
Present shortage of water supply
425 MCD
535 MCD
110 MCD
II Sewage
Present generation (in million litre a day)
Installed capacity of Sewage Treatment
Untreated Sewage
1700 MLD
1270 MLD
430 MLD
=:::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~@_ •••::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::=Module-l
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Reproductive & Child Health Care
III Electricity
Present power demand (in megawatt)
Generation of power by DESU
Thermal Power Station
Shortfall
Losses suffered by DESU
Total Number of consumers
1700 MW
375 MW
475 MW Total 850 MW
850 MW
Rs 2000 crores (approx)
18 lakh
IV Housing stock (1989)
Number of households in Delhi
Estimated current housing stock (including those
in the slum, squatter, unauthorised colonies)
Shortage of Dwelling Units (DUs)
Shortage of DDs by 1995
11.6 lakh
16 lakh
4.40 lakh
8.25 lakh
V Doctor nurse ratio
Number of doctors in hospitals
Number of Nurses
Nurses per doctor (as against the norm
of 3 nurses per doctor)
2839
5744
2.02
VI Ambulance Service
Total (Hospital:76, Fire Service:41, CATS:27)
Population served per ambulance
244
38403
VII Villages without sewage
Total urban villages
108
Villages connected with functional sewage
83
Village without sewage
25
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VIII Milk Supply
Milk requirement
Milk supplied by Mother Dairy
(set up in 1974, autonomous)
Milk supplied by Delhi Milk Scheme
(set up in 1959, state owned) (Accumulated
of over Rs 200 crore till 1991)
losses
Organised private sector and other state cooperatives
Shortfall
25 lakh litres per
day (llpd)
6.5 IIpd
4.5 llpd
4 IIpd
10 IIpd
REPORTED CASES FROM GOVERNMENT HOSPITALS
Disease
Cholera
Typhoid
Outdoor
-
1991
Indoor
8
2,617
1,664
Deaths
-
Outdoor
800
46 2,225
1992
Indoor
74
1,473
Deaths
-
53
Amoebiasis
Diarrhoea
Gastroenteritis
Tuberculosis
Pulmonary TB
18,250
-
18,837
26
4,450
590
-
889
2,297
1,458
9 19,212
417
19
0
-
-
-
31
-
-
-
287 12,105
3,383
449
122 3,729
1,637
199
Viral Hepatitis
2,413
428
28
760
324
40
Acute Bronchitis
35,408
Chronic
27,260
Bronchitis/ Asthma
764
1,921
42 92,430
800
98
71 43,515
1,849
88
Source: Directorate of Health Services, Delhi Administration
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Reproductive & Child Health Care
MAIN SOURCES AND HEAL TH EFFECTS
OF POLLUTANTS
Pollutant
Main Source
Effects
Suspended
cause
Particulate
Matter
Sulphur dioxide
Nitrogen Oxide
Ceramics & Glass
Thermal Power
Thermal Power, Chemicals,
Ceramics, Textines
Diesel Engines, Ceramics
Carbon monoxide
Two-wheelers, Engineering
Hydrocarbons
Two-wheelers, ceramics
Chemicals
Aldehydes /Chemicals
Lead
Petrol Engines, Water pipes,
Food cans, Batteries
Chromium & Nickel Alloys, Plating, Electronics,
Fungicides
Noise
Industry, Traffic
Mosquitoes
Bacteria
Virus
Worm infestation
Stagnant Pools
Infected water
Damage of lungs. May
bronchitis & asthma
Acid Rain. Damage to
lungs, eyes, skin
Forms smog. Damage to
respiratory system and
eye irritation
Toxic. Causes Blood
poisoning
Cancer
Cancer
Nervous system slows
down
and
brain
development is retarted.
Slows reaction time,
reduces attention span.
Cancer
Deafness, Irritation &
Nervousness
Malaria
Jaundice, Cholera,
Dysentery, Typhoid,
Diarrhoea, Polio, Worms
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PERCENT DISTRIBUTION OF THE RESPONDENTS
BY SELECTED HOUSEHOLD AMENITIES IN DELHI;
NFHS- 1992-93
Household Amenities
Slum Area* Non-slum Area Total
Type of Toilet Facility
Own flush, pit toilet
Shared flush, pit toilet
Public flush, toilet
No facility
Others
Source of Lighting
One
Two
Three or more
in HH
Separate
Yes
61.2
No
Room for Kitchen
Type of Fuel Used for Cooking
Electricity
Liquid Petroleum Gas
Kerosene
Others (Wood, Coal etc.)
Source of Water
Piped Water
Hand pump in the yard
Public tap
Public Hand Pump
Others
22.9
9.0
29.4
37.6
1.1
61.1
21.0
17.9
24.4
74.8
0.4
14.7
55.2
29.8
31.3
13.2
39.3
13.5
2.9
72.6
8.3
13.3
5.6
0.2
18.3
23.2
58.5
68.2
31.2
0.4
66.7
25.7
7.2
82.8
10.7
4.6
1.6
0.3
64.6
8.3
15.9
10.8
0.3
25.3
22.8
51.9
38.8
0.4
58.2
30.5
10.9
74.4
11.1
10.3
3.5
0.7
Source:
"Fertility, MCH Care and Family Planning Practices in Slum Areas of Delhi" by Dr Sanjay
Kumar, paper presented at seminar on 'Role of NGOs in Promoting Reproductive and Child
Health Services in Delhi Slums' held on 14th May, 1998 at PFl. New Delhi.
* The data on the type of house has been used to classify slum and non-slum areas from National
Family Health Survey. Those households having semi pucca or kaccha houses in the NFHS
sample have been termed as living in the slum areas. Non-slum areas include the households
living in the pucca houses. The results should be intrepreted with
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Reproductive & Child Health Care
Percent Distribution of Women Age 15-49 by
Selected Background Characteristics in Urban,
Delhi, NFHS, 1992-93
Age
15-19
20-24
25-29
30-34
35-39
40-44
45-49
Marital Status
Married
Separated
Widowed/Divorced
Education
Illiterate
Literate - Primary
Middle Complete
High School +
Religion
Hindu
Muslims
Sikh
Others
Caste/Tribe
Scheduled
Scheduled
Others
Caste
Tribe
,N
See foot
note
of Table
7
.f•..\\•.PFI
6.1
28.1
26.7
15.6
10.7
6.1
6.7
27.0
27.0
1.5
3.2
70.4
13.2
7.3
9.2
3.7
15.6
21.5
20.1
15.8
11.4
12.0
32.0
4.1
17.8
22.3
19.3
14.9
10.5
11.1
31.0
95.8
0.6
3.6
95.7
0.8
3.6
30.2
15.0
11.1
43.6
36.7
14.7
10.5
38.0
80.5
16.0
2.5
1.0
7.4
1.7
90.8
81.0
9.2
6.9
2.9
80.9
10.3
6.2
2.6
5.3
0.9
93.8
2650
5.6
1.0
93.4
3184
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MEAN DURATION OF OPEN BIRTH INTERVAL BY
SELECTED DEMOGRAPHIC CHARACTERISTICS OF
THE RESPONDENTS IN DELHI, NFHS
(IN MONTHS), 1992-93
Slum Areas
Non-Slum Areas
Total
Mean OBI
Age
<20
20-29
30-39
40-49
49.75
9.95
23.69
66.57
147.07
84.09
78.40
11.13
28.09
81.29
179.70
10.86
27.01
79.49
176.82
Parity
1
2
3
4+
Sex of the Last Child
Male
Female
33.76
37.63
57.77
59.33
53.92
44.13
45.80
80.59
93.74
99.44
85.52
82.25
43.82
74.51
87.99
92.10
80.24
76.04
N
453
See foot note of Table 7
2303
2770
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Reproductive & fh=i=ld=H=e=a=lt=h=C=a~=e======================:::====::::::====
PERCENTAGE DISTRIBUTION OF WOMEN
EXPERIENCED DEATH OF HER LAST CHILD BY
SELEOTED DEMOGRAPHIC CHARACTERISTICS IN
DELHI, NFHS, 1992-93
Slum Areas
Non-Slum Areas
Total
% of woman lost last child
Age of the woman
Less than 30 years
More than 30 years
Last Closed Birth Interval
<12
12-23
24-35
36+
48+
Parity
1
2
3
4+
Sex of the last Child
Male
Female
8.39
8.79
7.78
18.18
9.26
8.00
7.79
4.71
9.46
7.55
5.26
10.11
6.92
10.36
3.3
2.64
3.7
6.05
4.24
3.59
1.63
1.82
2.43
1.63
2.84
5.84
2.79
3.95
4.12
4.08
4.14
7.54
4.97
4.44
2.69
2.23
3
2.4
3.22
6.34
3.47
4.94
Seefaatnate afTable 7
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PERCENT DISTRIBUTION OF CURRENTL Y MARRIED
WOMEN BY CONTRACEPTIVE METHOD CURRENTL Y
USED, ACCORDING TO AGE 7 TYPE OF FP METHOD IN
DELHI, NFHS, 1992-93
Slum Areas Non-Slum Areas Total
% Currently using any method
% Currently using any
modern method
Current user by age
<20
20-29
30-39
40-49
Type of method
Pill
IUD
Injection
Condom
Female Sterilisation
Male Sterilisation
Periodic Abstinence
Withdrawal
Others
46.6
43.7
20.7
38.5
55.4
55.6
3.0
5.0
0.2
16.2
18.0
1.2
2.2
0.8
-
63.4
60.6
57.1
54.9
11.1
51.1
69.4
55.4
3.0
8.7
0.1
21.1
20.7
3.5
3.3
2.9
0.1
14.0
48.3
67.5
55.6
3.0
8.1
0.1
20.3
20.2
3.1
3.2
2.5
0.1
N
See footnote of Table 7
499
2539
3053
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Reproductive & f=hl="ld=H==ea=l=th=C=a=r=e===================================
MATERNAL AND CHILD HEAL TH CARE PRACTICES IN
DELH~ NFHS (PERCENT OF DELIVERIES DURING
LASJr FOUR YEAR PRIOR TO SURVEY), 1992-93
!
No ANC received
Slum Areas Non-Slum Areas Total
34.30
12.50
18.00
No ANC by Parity
1
19.67
45.80
53.40
2
35.61
27.20
24.70
3
26.53
25.50
20.30
4+
42.86
6.25
7.97
Children immunization
Ever Received Vaccination
Yes
No
BeG
DPT
Polio
Measles
Children suffered from
Diarrhoea during 1st 2 weeks
Treatment sought for diarrhoea
69.30
30.70
95.40
83.00
85.90
54.80
10.00
91.20
83.70
16.10
96.20
89.20
89.10
67.00
79.40
20.50
96.00
87.60
88.30
64.00
9.20
91.30
9.50
97.20
See footnote of TapIe 7
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ROLE OF NGOs IN REPRODUCTIVE CHILD HEALTH
cr Learning Objectives
• Specify the role ofNGOs in planning implementation, monitoring, and evaluation
of RCH programmes
~ Teaching Aids
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Reproductive & Child Health Care
Introduction
The growth of Non-Governmental Organisations(NGOs) has assumed gigantic proportion all
over the world. Their importance in the development panorama is almost crucial today. The
preference shown by many developed countries to NGOs for developmental activities amply
testifies this. In 1990, for instance, seven million US dollars reached NGOs for various
developmental programmes (Dr Gangrade, K.D.& Dr. Sooryamoorthy, R. NGOs Today, article
in social welfare, vol 44, No.1, April 1997)
The NGO sector is growing day by day. Over the years the role ofNGOs in development has
been very significant, particularly in the developing countries. In India, they are found in
almost all the areas of human activity. The activities are virtually multiplying in geometric
progression. They have taken up an array of roles : activists, environmental protectionists,
strong advocates of human rights, consumer protectionists and the like.
In the areas of welfare, education, health, sanitation, environment, human rights and social
justice the NGO sector has carved out a niche for itself. In fact, the works of the sector have
influenced government policies and programmes. Some NGOs have been successful enough
to change the attitude of government towards the neglected sections. There are instances where
NGO action could successfully deter the government from formulating anti-people and anti-
environment policies. Not only in India but in many developing countries governments have
been compelled to consult them. NGOs influence the path, course and direction of development.
NGOs have also been instrumental in preventing the state from becoming a tyrannical power.
What ;s an NGO?
UNFPA, in its draft guidelines for UNFPA, defines an NGO as:
" a not-for-profit, non-governmental body, legally established under the laws governing
such groups in the country of its headquarters. It normally has a written constitution and
by-laws, a governing board, a chief executive officer and staff. Most NOOs also have a
membership or constituency comprised of individuals, groups, or both."
In its broadest sense, the term NGO generally is taken to refer to all organisations:
(i) not based in government and
(ii) not created to earn profit.
While this broad definition of NGO is correct semantically, it presents a problem in that, it
embraces a large number and wide range of organisations that structurally and functionally are
unrelated. This broad definition of NGO refers more to what an organisation is not, rather than
to what it is, and can be applied to many kind of organisations ( Asian Development
Bank 1987).
In 1994, at the Cairo International Conference on Population and Development (ICPD),
governments unanimously endorsed, through the Programme of Action, the need" to promote
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an effective partnership between all levels of government and the fuH range of non-governmental
organisations and local community groups in the discussion and decisions on the design,
development and environment in accordance with the general policy framework of
Governments, taking duly into account the responsibilities and roles of the respective partners."
In addition, a call was made to governments and donors to ensure that NGGs are able to
maintain their autonomy and strengthen their capacity.
What is Reproductive Health ?
Most Government programmes have generally ignored the fact that reproduction takes place
through sexual relations which are conditioned by broader gender relations. A review of
conventional demographic and family planning literature illustrates that population field has
neglected issues related to sexuality, sexual decision-making, gender roles and relationships
and has focused largely on outcomes such as fertility decline, unwanted pregnancy and. more
recently, on infection. Clearly, social constructions of sexuality and gender relations have an
impact on reproductive health But, because they are generally considered to be politically
sensitive, these issues have been neglected.
By the middle of the '90s an appreciable softening among the population hard-liners became
evident. Many decades of pumping money into contraceptives and sterilisation had not yielded
desired results. In 1994, International Conference on Population and Development (ICPD),
recommended that the participant countries should implement unified programmes for
Reproductive Health.
The Cairo Conference became a turning point for the Reproductive Health (RH)
Programme which was 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 well-being and couples
are able to have sexual relations free of fear of pregnancy and of contracting diseases."
The World Health Organization (WHO), defines Reproductive Health as a state of complete
physical, mental and social well-being, not merely the absence of disease or infirmity.
The proponents of the reproductive health framework believe that reproductive health is
inextricably linked to the subject of reproductive rights and freedom and women's status and
empowerment. Thus, the reproductive health approach extends beyond the narrow confines
of family planning, to encompass all aspects of human sexuality and reproductive health needs
during the various stages of life. The concept of reproductive health is to provide to the
beneficiaries need based, client centered, demand driven, high quality and integrated RH
services. Reproductive health addresses the reproductive processes, functions and system at
all stages oflife. Therefore, it implies that people are able to have a responsible, satisfying, and
safe sexual life and that they have the capability to reproduce and the freedom to decide if,
when and how often to do so.
Reproductive and Child Health Approach (R.C.H.)
Following the ICPD, the Government of India decided to adopt the Reproductive and Child
Health approach. As a first step, method-specific contraceptive targets, which had so far been
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Reproductive & Child Health Care
the driving force behind the family welfare programme, were abolished in April 1996 and the
Reproductive and Child Health approach was launched in October 1997. Thus, at the
policy level a new paradigm hao;;been articulated. In a nutshell, RCH covers all aspects of
reproductive health and in addition, it covers the Universal Imrnunisation Programme (U.I.P)
and Child Survival and Safe Motherhood (CSSM) programme.
The ICPD agenda was relevant for India because the direct link between promoting family
planning methods and population stabilization was finally broken and population was placed
firmly within the broader issue of development. It was recognised that education, basic social
services and effective governance at the grass roots were critical in order to achieve population
and development objectives. The need for incorporating gender issues and shifting programme
focus to clients' needs and quality of care was widely acknowledged.
RCH is a composite programme incorporating the inputs of the Government of India, as well
as, funding support from external donor agencies including the World Bank and the
European Commission.
Reproductive Health emerged as the new panacea for all problems. Demographers, family
planning service providers, women's organisations, advocates of women's health, donor agencies
and the Government saw in the phrase 'Reproductive & Child Health', an opportunity to do
what they wanted - without attracting too much attention:
• The government saw in Reproductive & Child Health (RCH) a new label, a new slogan
to merge safe motherhood programmes with family planning and add Reproductive
Tract Infections (RTIs) and Sexually Transmitted Diseases (STDs) and adolescents
into the mixture.
• Some donor agencies saw this as a good opportunity to call for a more decentralised
effort to step up contraceptive services towards accelerating fertility decline, without
the stigma of the earlier family planning programme.
• Family Planning service providers saw it as an opportunity to continue doing what they
have been doing, after adding some women's sexual health issues - RTls and STDs.
• Women activists saw in RCH an entry point to bring centre stage issues of women's
status, autonomy, sexuality, violence and human rights.
• Women's health advocates saw a flicker of hope of moving away from the dominant
perception of women as baby producing machines to human beings who go through a
life cycle of deprivation and ill-health.
.
• Health groups saw this as yet another vertical programme that deflected attention from
holistic, good quality, primary health care. Yet, they were pleased that women's health
would at least get the attention it merited.
• HIV/AIDS lobby was pleased that sexuality and sexual health would finally
receive attention.
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• Almost everyone felt they had something special and new in this catch-all phrase. Most
importantly, it provided the much needed space to talk about sex, sexuality, male
responsibility, public and private behaviour, autonomy, violence and a host of related
issues. The entire debate centered around women's control over her own body, her right
to say 'no' and 'enough'.
Magnitude of Problems
• The population oflndia in mid-1995, estimated around 920 million, is growing annually
at the rate of 1.94%1.
• India has amongst the high~st maternal mortality rates known in the world. The recently
completed National Family Health Survey reports the ratio for the country to be 420/
1,00,000 live births, with 55/1 ,00,000 women of child bearing ages succumbing to
maternal causes. Approximately 1,10,000 women die in India because of pregnancy
related problems.
• 15% of all deaths of rural women aged 15-24 are attributed to complications of pregnancy
and child birth (lIPS, 1995)2.
• Prevalence of adolescent marriages. In 1961, for example, as many as 70% of all
adolescent females aged 15-19 were currently married (Pathak and Ram, 1993)3. By
1981, this fell to 44%, and by 1992-93 to 39%. Wide regional variations persists in age
at marriage and at consummation. Adolescent marriage continues to be widespread,
and the median age at marriage is 15 or less in four northern States - Bihar, Madhya
Pradesh, Uttar Pradesh and especially Rajasthan.
• Sexual initiation occurs relatively early, by ages 17-19 in most cases. (Goparaju, 1993)4.
• 10% of all adolescent pregnancies end in miscarriage or stillbirth compared to 7%
among older women (UPS 1195)5.
• Adolescents are poorly informed about their own sexuality and physical well-being.
Whatever knowledge they have, moreover, is incomplete and confusing.
• Adolescent girls are generally ignorant of menstruation until it occurs. Even then,
knowledge is limited to the mechanics of menstruation, and to related behavioural norms,
and not necessarily its link to sex and reproduction. (Bhende, 1995)6.
• Knowledge of sex and reproduction are even more limited, both among college going
girls and among younger boys and girls residing in urban slums (Bhende, 1995)
• Contraceptive awareness is equally vague, even among married adolescents (ORG, 1990)7.
4 Lakshmi Goparaju, 'Unplanned, unsafe: male students' sexual behaviour,' Paper presented at the workshop on
Sexual aspects of AIDS/STDs Prevention in India, Bombay, 1993.
5 International Institute for Population Sciences, 1995.
6 Asha Bhende. A Study of Sexuality of adolescent girls and boys in underprivileged groups in Bombay' The
Indian Journal of Social Work, 1994.
7 Family Planning Practices in India: third All India Survey. Operation Research Group, Baroda 1990.
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Reproductive & Child Health Care
• Awareness of sexually transmitted diseases and AIDS is 25% and 32% amongst poorer
and younger adolescent girls and boys respectively (Bhende, 1995).
• 40% of abortion seekers, in one study, reported that contraceptive decision making was
left to the male (Mandal, 1982)
• According to WHO, at least half of those infected with HIV are under 25, with 15-19
age group having the second highest rates of AIDS.
• A recent study found 90% of pregnant women to be anaemic (below 11g/dl of
hemoglobin).
• A 1986 community-based ICMR study on pregnancy wastage found that 8 out of every
100 pregnancies do not end in live birth, and that if the high mortality of premature
births is taken into account, almost one in ten pregnancies may not even have a positive
outcome.
In addressing the needs of women and men, the reproductive health approach places an emphasis
on developing programmes that enable clients to make informed choices; receive screening,
education and counselling services for responsible and healthy sexuality; access services for
preventing unwanted pregnancy, safe abortion, maternity care and child survival, and for the
prevention and management of reproductive illnesses including reproductive tract infections
(RTls), sexually transmitted diseases (STDs), and gynaecological problems. Thus reproductive
health programmes are concerned with a set of specific problems, identifiable clusters of client
groups, and distinctive goals and strategies.
Strategy
The RCH programme is now geared up to address the above mentioned issues by using the
following strategies:
• Community participation in planning for services and prioritizing
• Client-centered approach to service provision
• Upgrading facilities and improved training
• Emphasizing on good quality care
• Absence of contraceptive targets and incentives
• Making services gender sensitive
• Having a multi-sectoral approach in implementing and monitoring services
New Approach
At Cairo, the nations of the world agreed that the focus should be on individual needs instead
of demographic targets and that governments should give special attention to the education of
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Role of NGOs in Reproductive Child Health
girls, the health of women, the survival of infants and young children, and in general to the
empowerment of women. Post ICPD, a truly new approach emerged which is as follows:
• Need based participatory planning
• Community involvement in planning, monitoring and surveillance
• Multi-sectoral participation in health and nutrition services
• Self estimated goals by health workers
• Integrated package of services
• Good quality of care
• Educating community to adopt correct health practices
Role Identification for NGOs
Given the unique Indian situation - of geographical and socio-cultural diversity within and
between the states and regions, it is imperative that the government machinery should play the
dominant role in improving the conditions of the millions of the people. Government machinery
includes the vast bureaucratic establishment, judiciary, peoples' institutions, and government
promoted development agencies. Nevertheless, non-governmental organisations (NGOs)
continue to have a crucial role in the overall development efforts in the country. On one hand
the government endeavor dominates the national and regional scene, on the other, importance
ofNGOs in micro/locallevel intervention cannot be ignored. There are areas where NGOs and
government agencies can and should work together in the interest of people. It is a question
of who plays what role and at what level.
It is well known that government agencies implement programmes, which are planned at the
macro level for the benefit of a large section of population. Whereas, the NGOs work in
isolated pockets, on issues touching the people, at the grassroots.
RoleofNGOs
In 1994, at the Cairo International Conference on Population and Development (ICPD),
governments unanimously endorsed, through the programme of Action, the need "to promote
an effective partnership between all levels of government and the full range of non-governmental
organisations and local community groups in the discussion and decisions on the design,
implementation, coordination, monitoring and evaluation of programmes relating to population,
development and environment in accordance with the general policy framework of
Governments, taking duly into account the responsibilities and roles of the respective partners".
In addition, a call was made to governments and donors to ensure that NGOs are able to
maintain their capacity.
NGOs have a role in national and intemationallife. NGOs are becoming increasingly important
players in family planning, environmental and developmental policy making in the developing
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Reproductive & Child Health Care
world. NGOs can be a truly independent voice, either by serving as a focal point for people or
by serving as models for new governmental programmes. NGOs can place pressures on
governments to create and implement new policies. They can also worm in partnership with
governments, though such alliances carry the risk of dependence on government funds.
This shift in the philosophy and methodology of the programme calls for the communi ty's and
the NGO's participation for planning, implementation and monitoring.
NGOs can assist in encouraging opinion leaders, women members of Panchayats, local
traditional dais, anganwadi workers and private practitioners to participate in planning need
specific RCH programmes.
NGOs can also provide feed-back to the public health system and by day- to- day surveillance
of implementation process can ensure quality of care.
NGOs can solve some pieces of the development puzzle by taking an unconventional approach;
by listening carefully to what people want and working to enlist their participation and support,
or by trying to foster and manage natural resources.
The basic tasks of the NGO workers addressing population issues are to supply contraceptives
to eligible couples, to give talks on breast feeding, child health, birth spacing, and health-
related education and to carry out grass-roots- level development programmes. They can also
provide additional information on prevention of sexually transmitted diseases and Acquired
Immuno Deficiency Syndrome (AIDS).
The Ministry of Health and Family Welfare, for effective implementation of Reproductive &
Child Health (RCH) has decided to work through a network of small NGOs, mother NGOs,
and national NGOs, but the role of International NGOs is equally important to support the
RCH programme.
Small NGOs work at the grass-root level basically for advocacy of RCH. Grass-roots
organisations can make numerous contributions to sustainable development. They can
mobilize local people and resources to support project activities over the long run;
enable all the people of society to improve their quality of life; increase their own
effectiveness to potentially influence national policy-making, either through growth or
building alliances; link all the elements of sustainable development, including ecology,
economics, politics, and culture; and enable individuals to cope with change.
Mother NGOs' role is to support, monitor and evaluate and provide training to the
small NGOs .For this they are accountable to national NGOs.
Developmental national NGOs, also playa significant role. They can help resolve the
economic and cultural differences among local organizations, government agencies,
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Role of NGOs in Reproductive Child Health
and national institution; use their money and expertise to help grass-roots NGOs;
. bridge gaps between local practice and technical knowledge in the effort to find long-
term solutions that are widely accepted by the target groups; find new approaches to
solving problems and disseminate this knowledge to other organisation; and provide
connections by joining networks or building links with international organisations.
International NGOs can offer national and local NGOs new ideas and include them in
ongoing international policy-making. These NGOs can serve as international lobbyists
to criticize constructively the policies of governments, corporations, and multilateral
institutions. International NGOs also can show how otherwise disconnected
communities share similar problems and can increase awareness of global issues,
such as deforestation, loss of bio-diversity, and global warming.
A number of crucial factors operate behind the success of the programmes run by
NGOs. The advantages of NGOs include their flexibility, innovative capacity,
resourcefulness, ability to be of benefit to beneficiaries in an expedient manner, and
ability to work in sensitive areas. In addition, NGOs also mention some operating
principles such as participatory training, supportive supervision, close monitoring,
uninterrupted supplies, community involvement, more favourable worker- population
density and better incentives to service providers. Success of NGOs has been brought
about by the interplay of a number of factors which are discussed below:
• Leadership: NGOs are often run by dedicated and committed leadership with a
clear vision and objective.
• Flexibility: With new experiences gained , NGOs can quickly change their
strategies and adopt and experiment with new innovative ideas.
• Training: Task-oriented training is considered an ongoing activity.
• Management and supportive supervision: NGOs are normally small, therefore
management and supervision is more decisive and supportive.
• Uninterrupted supply: NGOs working in the field of reproductive health, by using
their own influence or additional resources, have been better able to ensure
contraceptive supplies.
• Mobilization of resources: NGOs have been very successful in mobilizing both
local and external resources for their programmes.
• Community participation and accountability: NGOs very easily mobilize
community participation in the project, increase demand and generate local
accountability because of their work with grass-roots level.
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Reproductive & Child Health Care
• Integrated approach: NGO programmes come as a package keeping in view "
felt needs" with tangible gains. The reproductive health programme is more effective
in such situations.
• Client oriented approach: NOD programmes offer client-oriented approach rather
than method oriented approach generally offered by government programmes.
Government vis-a-vis NGOs
The era of globalisation and liberalisation brought with it new NOO enthusiasts. For almost a
decade now, NODs have been seen as the ideal agency that would cut through red-tapism,
inefficiency and corruption and reach much-needed health care services, credit, education and
so on to the poor. NODs were seen as being more efficient and closer to the people. In wake of
the Panchayati Raj Act, their role in galvanising 'women power' was the new path to
empowerment.
With the exception of a few staunch NOD advocates, most government officials are apprehensive
about viewing NOOs as a magic solution. Most officials point out that the NOD sector is not
as rosy as it appears. Proximity to powerful people, dependence on foreign funds and emergence
of a large number of bogus organisations have forced attention on the dangers of 'handing
over' social service to them. Most government officials express reservation about involving
NODs 'in policy-making and programme development. They argue that foreign funded NODs
are not 'independent' as they are the mouth pieces of their financiers.
It is rather ironical that 'independent' or truly 'voluntary' NODs are limited in numbers rare.
Despite inherent contradictions and conflicts, working among the poor requires commitment.
Salary scales are rather low in most agencies, Bare subsistence wages, long working hours,
absence of job security, health care benefits and provident funds coupled with almost no
career advancement for local employees has set this sector apart from the rest of the economy.
There have been innumerable heroic tales about dedicated workers and organisations. Alongside,
there have been many incidents of corruption, exploitation, refusal to pay minimum wages,
and family control. Over the years, competition among NOOs has become fierce.
Accountability, commitment and proximity to the people have become a rare quality. Not
withstanding the dismal picture, it is significant to note that despite erosion of fundamental
values, there are many organisations and groups that remain steadfast and continue to uphold.
The ideas of dedicated service.
The past 50 years experience bears out that the government alone cannot ensure the required
pace of health improvement including involvement of people and communities and NOOs are
considered as valuable partners supplementing the efforts, of the public health sector.
Some initiatives of RCH programme to facilitate NGOs
performing their expected RCH Roles Better
A systematic effort is being made to increase substantially participation opportunities for NOOs
in the RCH programme, particularly in selected service areas and is difficult to reach regions
or population groups. For this, certain interventions have already been initiated like:
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Role of NGOs in Reproductive Child Health
• Revision of standard maternal and child health (MCH) and family welfare guidelines
for NGO projects funded by the Government of India.
• Conversion of State Commission of Voluntary Associations (SCOVA) to register
societies to increase flexibility and provide built-in evaluation of projects at the
State level.
• Revised guidelines for social marketing to facilitate greater participation of state level
social marketing NGOs and/or agencies.
• Contractual arrangements for utilising NGO facilities of skill, experience, and staff
with a view to enhancing public sector's capacity for service delivery.
• Provision of contractual arrangements for utili sing services for IEC, training, monitoring
and evaluation and to encourage social marketing.
• Provision to enable participation of NGOs in the management of emergency referral
funds at the grass-roots/sub-centre/village-Ievel.
Implementation Strategies and Constraints
Five years after the ICPD, a consultation was held at Hague in January 1999 to take stock of
how far we have succeeded in implementing the ICPD agenda, reflect on lessons learnt and
identify the steps to be taken in the next five years. The following issues related to
implementation process were identified during the consultation:
A. Decentralised Planning, Monitoring and Evaluation;
B. Human Resource Development;
A. Decentralised Planning, Monitoring and Evaluation
During the consultation it was realised that decentalised planning, monitoring and
evaluation led to empowering partnerships between the government and NGOs or the
government and clients/community.
Constraints
• The main problem with the process of decentralisation is lack of motivation
on the part of the providers to implement services now that there is no pressure
to meet targets. The spirit of target free approach has not percolated to the
field level.
• Reluctance of middle level officials to take decisions which they perceive as
"administrative risks". In a situation that is still evolving, the tendency is to
wait and watch rather than to move ahead.
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Reproductive & Child Health Care
• The role of panchayats in the process of decentalisation needs to be examined
in light of what their responsibilities are and what resources are under their
control.
The next 5years
The critical next steps identified were:
• Promote, advocate, and strengthen the state level initiatives for guided
decentralisation.
• Give more emphasis to empowerment of clients using diverse strategic
mechanisms such as Jan Mangal, Mahila Samakhya and Healthwatch.
• Capacity building at district and primary health centre levels to enable planning,
including redefining the role of supervisors.
It was felt that the key issue pertaining to human resources was the way in which
training was designed and delivered.
Constraints
• Lack of conceptual clarity because of which training is seen in isolation, as an
event, and not as part of a process .
• No follow-up or monitoring indicators to assess impact of training on the
performance of trainee.
• Lack of proper training methods and materials.
• Lack of support systems and incentives that encourage trainees to transfer
inputs from the training into their work.
The next 5 years
It was felt that in the context of the reproductive and child health programme, it was
important to find the systemic causes that led to staff related problems such as lack of
motivation and accountability and to deal with these in a strategic manner.
• Training must be seen as a continuous process
• NGGs should be involved in the training, its design and selecting appropriate
methods and materials.
• Training should focus on awareness generation, skill development and
experiential learning.
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Role of NGOs in Reproductive Child Health
c. Partnerships and Integration
It was felt that there is a need for prudence in the selection of partners and what is a
good partnership is context and locale-specific. It was strongly felt that the government
must continue to be the 'doer' and expand its role in providing basic education and
health services.
• There is lack of conceptual clarity and the relationship is often not one of
equality, shared vision and mutual respect.
• The tendency is to look for partners in implementation rather than involving
them in the planning stage.
• There is no mechanism to involve them in the discourse on gender, rights
and health.
The next 5 years
• The first step should be to build trust between different stakeholders:
Government organisations with Non-governmental organisation, Non-
governmental organisations can form partnerships with other NGGs. GOVl.
organisations can liaison with other sate government organisations or with
the corporate sector for better coordination and implementation of
welfare projects.
• Terms such as partnership and integration need to be clarified before making
linkages with other sectors.
• Various groups and NGGs should come together to define common goals and
shared concerns.
• Identify anyone area around which partnerships could be built and develop
skills for integration.
• Partners should be able to work together on common issues while continuing
to disagree on others as long as these differences do not affect the partnership.
Recommendations
• NGGs' involvement is imperative in policy formulation and in programme planning,
implementation, monitoring and evaluation
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• NGO programmes should be complementary and supplementary to government
programmes
• Networking and collaboration amongst NGOs is essential
• NGOs should strive towards self-sustainability
• There is a need to improve accountability and transparency of NGO operations
• The management information system (MIS) of the government should comprehensi vely
reflect the performance of NGOs
• An independent coordinating body is necessary to facilitate Government-NGO
cooperation. It should also develop a code of ethics for NGOs
• NGOs' comparative strengths should be utilised, as appropriate, in addressing culturally
and socially sensitive issues
• Commitment to Government-NGO cooperation at all levels, including at the highest
political level, is essential.
Lets sum Up
Over the past two decades, NGOs have assumed a broader and increasingly important role in
development. NGOs have expanded significantly in number, size and degree of influence, and
their scope of work has widened to the extent that NGO involvement and concerns address
nearly every human need and endeavour. The degree of professionalism that NGOs display
continues to increase, and NGOs are gaining access to significantly large amounts of resources,
both financial and human. Recognized as an important force in development, NGOs have
assumed a significant position in the development community, independently and in partnership
with governments, development institutions and donors. NGOs work at local, national, regional
and international levels.
The ICPD process brought the international community together around one of the most pressing
problems of our time and enabled both developed and developing countries to reach consensus
on a wide variety of issues. The challenge now is to transform this consensus into action.
The first major step that the government took was to remove contraceptive targets. The country
has become 'target free'. However, to translate reproductive rhetoric into reality, two important
issues must be addressed. First, a paradigm shift is essential. And, second, packages of good
quality services must be designed and implemented to address reproductive health needs of
people. A shift in paradigm implies a change in focus: from a population control approach of
reducing numbers to developing programmes designed to address the reproductive health needs
of people.
The programme should be monitored and evaluated now that the targets have been removed.
Indicators for measuring the quality of health services from the perspective of clients are,
therefore, urgently needed. The government should realise its limitations and make a concerted
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Role of NGOs in Reproductive Child Health
effort to work in partnership with a range of institutions, the corporate sector, NGOs, panchayats,
and most importantly with the people, to achieve its goals.
It is clear that NGOs can go a long way towards fulfilling the objectives of development
programmes. Reproductive and Child Health is no exception. However, as mentioned before,
NGOs are mostly interested in their own programmes and unless efforts are made to replicate
the positive aspects of NGO activities in the rest of the country, either by NGOs or by others,
including the government, the impact of such efforts will remain only marginal.
Frequently, NGOs are in closer touch with people at the grass-roots level. Often, non-
governmental organisation are more innovative, experimental and flexible in tackling issues,
including more sensitive issues such as family-planning, reproductive health and rights of
youth and adolescents. such experience can make a valuable contribution in complementing
the work of governments and international agencies.
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Reproductive & Child Health Care
Questions
2.. Identify the main components of RCH.
3. What are the reasons for the shift leading to the RCH Approach.
4. What specific roles can NGOs play in promoting RCH programmes.
5. How and why are NGOs considered as important agencies in implementation and
promotion of RCH programmes.
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REPRODUCTIVE SYSTEM AND REPRODUCTIVE HEALTH
qr Learning Objectives
• Understand the reproductive system, its functions and processes
• Comprehend various dimensions of responsible and safe sexual behaviour and
healthy sexual practices
• Describe the signs and symptoms suggestive of RTls/STDs
• Describe the preventive measures for STDsIHIV/AIDS.
'& Teaching Aids
• Chart paper
• Flip charts
• Writing material
• Sketch pens
• Slides
• Transparencies
• Flash Cards
• Models
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Reproductive Health
Reproductive health is the state of complete well-being in all matters related to the
reproductive system.
To elaborate, it is a state of complete physical, mental and social well-being and not merely the
absence of disease or infirmity, in all matters relating to the reproductive system and to its
functions and processes.
Implications of Reproductive Health
Reproductive health implies that:
• people are able to have a satisfying and safe sex life
• they have the capability to reproduce
• they have the freedom to decide whether, when and how often to do so. Implicit
in this condition is the right of men and women to be informed of and to have
access to safe, effective, affordable and acceptable methods of family planning of
their choice.
• the right of access to appropriate health care services that will enable women to go
safely through pregnancy and childbirth and provide couples with the best chance
of having a healthy infant.
Reproductive Health Care (RHC)
RHC is defined as the combination of methods, techniques and services that contribute to
reproductive health and well-being by preventing and solving reproductive health problems.
It also includes sexual health, the purpose of which is the enhancement of life and personal
relations, and not merely counselling and care related to reproduction and sexually
transmitted diseases.
Reproductive rights of an individual
Reproducti ve and sexual health is a right for both men and women. Every couple and indi vidual
has the following reproductive rights:
• to decide freely and responsibly the number and timing of birth of
their children
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• . to attain the highest standard of sexual and reproductive health
• to make decisions by oneself without any coercion or violence (voluntarism)
Importance of Reproductive Health of a Community
One should be aware of the reproductive health status of a community for the
following reasons:
• Improved Reproductive Health ensures easier, fruitful pregnancy and survival of the
new-born
• RTIs/STDs lead to pregnancy wastage, ego abortions, still births, etc. They may also
cause infertility
• RTIs/STDs also restrict the use of Family Planning methods; ego IUCD (intra uterine
contraceptive device) is not recommended for clients with RTIs/STDs.
Major considerations in Reproductive Health
In order to understand the functions of male and female reproductive systems, it is imperative
that we start with the anatomy and physiology of the reproductive system.
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6.1 Page 51 |
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Reproductive & Child Health Care
Anatomy and Physiology of the Reproductive System
The organs of reproduction are classified into:
r
External
I
1
Internal
1. Mons pubis
1. Uterus
2. Labia majora
2. Fallopian Tubes
3. Labia minora
3. Ovaries
4. Clitoris
5. Vestibule
6. UrethalOpening
7. Vaginal Opening & hymen
8. Vagina
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• External genitalia
The external genitalia are commonly called vulva. They include all the structures visible
externally in a female.
-+ Mons pubis
The mons pubis is a fat-filled cushion that lies over the pubic bone. After puberty,
the skin of the mons pubis is covered by curly hair. The distribution of pubic hair
differs in the two sexes. In women, it is distributed in a triangular area, the bas.e of
which is formed by the upper margin of the pubic bone and a few hairs are distributed
downwards over the outer surface of the labia majora. In men, the pubic hair grows
in a region that extends upwards towards the umbilicus and downwards and inwards
over the inner surface of the thighs.
-+ Labia majora
T he labia majora are fat-filled folds of skin that extend downwards and backwards
from the mons pubis. Embryologically, the labia majora are homologous with the
scrotum of men.
Two flat reddish folds of tissue that are visible when the labia majora are separated.
There are no hair follicles, but there are many oil secreting glands and sweat glands.
These structures are extremely sensitive as they have a variety of nerve endings.
The clitoris, the homologue of the penis, is a small, cylindrical, erectile body that is
located near the upper part of the vulva. It is richly supplied with nerve endings that
make it highly sensitive to touch, temperature and pressure. The clitoris is believed
to be the principal erogenous organ in women.
It is an almond-shaped area that is enclosed by the labia minora laterally. The urethra
and vagina open out into the vestibule.
-+ Urethral opening
The urethral opening is in the midline between the clitoris and vestibule.
-+ Vaginal opening and hymen
The vaginal opening is covered by a thin membrane called hymen. The hymenal
opening may be of various shapes - crescentic, circular, cribriform, septate or
fimbriated. The menstrual blood flows out through this opening.
========::======::==::=::==::=::=::=::==::=::=::=:::=:!0t:===========Module-3
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The vagina is a tubular structure that extends from the vulva to the uterus. It is an
organ of many functions: the excretory canal of the uterus through which uterine
secretions and menstrual blood escapes; the female organ of copulation (intercourse);
and part of the birth canal at the time of child birth.
1
The Female
External
Genitalia
• Internal genitalia
-+ Uterus
The uterus is a hollow muscular organ. During pregnancy, the uterus serves for
reception, implantation, retention and nutrition of the foetus. The uterus resembles
a flattened pear in shape and consists of two major but unequal parts; an upper
triangular portion (body) and lower cylindrical portion (cervix). The fallopian tubes
emerge from the upper comers of the uterus.
The intermost portion of the uterus that lines the uterine cavity is a thin, pink,
velvet-like membrane (endometrium). This membrane is cast off every month
leading to menstruation.
The fallopian tubes or oviducts extend from the upper corners of the uterus to the
ovaries and provide the pathway for the ova (eggs) to reach the uterine cavity.
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The ovaries are two almond shaped sex organs of the female, the functions of which
are the development and extrusion of ova (eggs) and the synthesis and secretion of
female hormones. (A hormone is a chemical substance produced in an endocrine
gland and transported through the blood to a certain tissue or organ, on which it
exerts a specific effect). The two female hormones secreted by the ovaries are
called oestrogen and progesterone.
It is the age at which menstruation first occurs. It usually happens between
12 and 14 years of age.
===========================~0:=====================MOdule-3
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-+ Menopause
It is the age at which menstruation stops. It sets in around the age of
45-50 years.
PASSAGE OF A MATURE OVUMTHROUGHTHE FALLOPIAN
TUBE AND RESULTANT MENSTRUAL BLEEDING
Ovulation refers to the physical act of expulsion of a mature ovum or egg from the
ovary into the fallopian tube.
From the first stage of its development, until after menopause, the ovary undergoes
constant change. The number of ova at the onset of puberty has been estimated at
2,00,000 to 4,00,000. Since only one ovum is ordinarily cast off during each
menstrual cycle, it is evident that only a few hundred ova (400-450) suffice for the
purpose of reproduction and the rest of them die naturally. Each ovum or egg is
lodged in a small follicle or capsule in the ovary. One follicle alone matures in each
month to let out one mature ovum .
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• Hormonal Influences on the Female Reproductive System
Name of female sex hormones - Oestrogen & Progesterone.
Site of Production -
Ovaries
-+ Role of Hormones
Cyclical fluctuations in these hormone levels establish the menstrual cycle. The
oestrogen is produced before ovulation and stimulates the uterine lining to grow.
After the release of the ovum (usually during mid-cycle) progesterone is secreted
which thickens and softens the uterine lining and prepares the bed for the
fertilised ovum.
If the ovum is not fertilised, the level of oestrogen and progesterone decline. The
uterine lining cannot be maintained without these hormones and is shed. This leads
to menstruation.
Following menopause, the ovaries stop developing ovum and stop secreting
oestrogen. Oestrogen is also beneficial for other reasons:
.:. it maintains good cardiovascular function
.:. it prevents heart attacks
.:. it prevents weakening of bones and guards against fracture
Remember
Ovulation takes place 14days prior to the next menstrual cycle.
Pregnancy
During sexual intercourse, millions of sperms are deposited into the vagina. The sperms
swim up through the cervix into the uterus, and reach the fallopian tubes, seeking a
mature ovum. If a mature ovum is present, one sperm meets with it. Although millions
of sperms may be present, only one sperm cell can penetrate the ovum. This is called
fertilisation and takes place in the fallopian tube.
PATH OF EMBRYO FROM
FALLOPIAN TUBE TO UTERUS
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• Implantation
The fertilised ovum moves through the fallopian tube into the uterus, where it gets
embedded in the thick and spongy uterine lining. This process is called implantation.
. ~\\ r
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.- ~ Ovum
/~
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2 cell
stage
Fallopian
tube
ova
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4 cell
stage
•.
Morula
0 "-.
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BI.,'ocy,t
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penisj
Testes i
• Development of Foetus & Placenta
In the uterus, the fertilised ovum grows and develops into a foetus and the membranes
around the fertilized ovum develop into placenta .
. After fertilisation, the single cell egg rapidly starts multiplying. It draws its nutrition
from the uterine wall during the first few weeks. By 12 weeks (i.e. 3 months) it is
possible to distinguish the tiny face, spine and limbs. This is called embryo and it
floats in a thin membranous sac, attached to the uterine wall with the placenta.
The foetus takes about nine months or approximately 280 days to grow into a fully
mature viable baby capable of independent existence.
The functions of the placenta are:
.:. to provide a firm attachment of the baby to the uterine wall
.:. to provide nutrition and oxygen to the baby from the maternal blood .
•:. to discharge carbon-di-oxide and other excretory products from the baby's
body into the maternal circulation. This to and fro transportation occurs
through the umbilical cord which thus acts as a communication between the
baby and the mother, via the placenta .
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Reproductive System And Reproductive Health
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• The Male Reproductive System
The penis is a spongy organ that is dotted with small blood vessels. During
sexual arousal, there is increased blood flow to the penis, resulting in swelling
of the organ. The penis (especially the tip which is called glans penis) has many
nerves, making it highly sensitive to touch, pressure and temperature. The skin
that covers the penis is freely movable and forms the foreskin. The urethra runs
through the middle of the penis.
The scrotum is a thin loose sac of skin underneath the penis that is sparsely
covered with pubic hair. The scrotal sac contains the testes. Sperms are produced
in the testes.
The testes are paired structures contained in the scrotum. The two testes are
usually equal in size, although one testicle generally hangs lower than the other.
They have two separate functions - hormone production and sperm production.
SE1v1INAL~
VESICLE
URINARY
BLADDER
VAS DEFERENS
-.- __
GLANS
PENIS
FORESKIN
.a.ttt.a.PF1==============:=:@!=:===================
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• Epididymis & Vas deferens
The epididymis is a highly coiled tubing network folded against the back surface
of each testes. Sperms usually spend several weeks travelling slowly through
the epididymis as they reach full maturation. From here the sperms are carried
to the vas deferens.
• Prostate & Accessory glands
The prostate gland is located directly below the urinary bladder and surrounds
the urethra (tube through which urine passes). The other accessory gland, the
seminal vesicle, produces seminal fluid, the liquid that is expelled from the
penis during ejaculation. Each ejaculate contains 3-5 ml of semen (seminal
fluid plus sperm).
There are about 40-120 million sperms per ml, which means that
120-600 million sperms are expelled per ejaculation.
The male produces sperms from puberty onwards, manufacturing billions of sperms
annually, unlike the female who creates no new eggs after birth.
Name of male sex hormone
Site of Production
Role of hormones
Time period for Production
Testosterone
Testes
Controls male sexual development.
70 days.
1. Head
2. Middle piece
3. Tail
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• Sex Determination of Baby
+ Boy or girl?
The sex of a baby depends on the type of sperm which has fertilised the egg. All
women have only one kind of chromosome in the ova (X). Men have two kinds of
chromosomes in the sperms (Xand Y). If the first kind of male chromosome (X)
fertilises the ovum, a female baby is born. If the second type of chromosome (Y)
fertilises the ovum, a male baby is born. This happens by chance and not by choice.
A woman thus has no role in determining the sex of an infant.
••
r
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Adolescence
Adolescence is the stage between childhood and adulthood. There is an increased rate of physical
growth in terms of height and weight during adolescence. The most important event of
adolescence is puberty, which is sexual maturation. It usually occurs between the ages of 10-
19 years. In girls, there is increased secretion of female hormones leading to maturation of the
vagina and uterus. Pubic hair and breasts also develop. Breasts consist of milk glands and
fatty tissue. During pregnancy the breasts enlarge further and prepare for secretion of milk
immediately after the child is born. In boys, due to increased secretion of male hormones,
pubic hair, moustache and body hair develop. The voice also changes. During this phase,
besides physical growth and sexual development, emotional and behavioural changes
also occur.
Adolescents are poorly informed about their own sexuality and physical well-being. Whatever
knowledge they have, moreover, is incomplete and confusing. Low rates of educational
attainment, limited sex education and inhibited attitudes towards sex attenuate this ignorance.
In fact, adolescent reproductive health needs are poorly understood and ill served in India. In
a country in which adolescents aged 10-19 represent one-fifths of the population, the health
consequences of this neglect take on enormous proportions. Inspite of this, adolescents have
remained invisible at the policy level.
In India, traditionally, the transition from childhood to adulthood amongst girls has tended to
be sudden. The existing social taboo on the subject of sexuality has resulted in limited vocabulary
and spaces to talk about this issue, especially amongst adolescents. Gatekeepers (parents,
teachers, policy-makers, etc.) do not visualise that adolescents need to know about sexuality
and sexual health issues. Sexual health and sexuality have only recently entered the discourse
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in the social milieu due to the overriding threat of HIVIAIDS. However, even today discussions
are veiled in innuendoes and continue to skirt the real issues.
A focus on adolescent health calls for comprehensive collaborative programming to include:
• information on sexuality, fertility and contraception, as part of their 'reproductive rights ';
• development of self-awareness, as positive self-image, assertiveness and an
understanding of gender-based discrimination and control of women's sexuality;
• development of psycho-social skills such as decision-making, problem solving,
effectively articulating, and coping with emotions and stress;
• development of survival/practical skills such as literacy and training for an occupation.
This is especially important in our setting where the majority of adolescents are out-of
school, illiterate and have limited work opportunities.
• design locally relevant interventions that eliminate the mortality that girls in this age
group suffer.
• Prioritising Issues for Adolescents
=> Access to quality education and information (primary as well as legal literacy, non-
formal, sex education)
• Programme recommendations
=> Disseminate family life education to in and out of-school youths
=> Investigate reproductive health needs and decision making authority amongst
married adolescent girls
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::) Investigate pre-marital sexual behaviour, awareness and attitudes amongst
representative samples of adolescent girls and boys
::) Describe the levels, patterns and context of abortion behaviour among both
unmarried and married adolescent girls and awareness of it legal status
::) Conduct community-based studies on obstetric and gynecological morbidity
amongst adolescent girls, and sexually transmitted infections amongst boys
and girls
::) Investigate adolescents' access to health care, and the constraints they face in
acquiring good health
::) Use rigorous, in-depth, and at the same time, sensitive and culturally appropriate
research designs to elicit data about adolescents
Advocacy needs to be an integral part of the programme and linkages need to be established
with the government and relevant partners. Partnership with the media should be built in order
to reach out to youth by developing role models, promoting healthy lifestyles, providing accurate
information, etc.
Media is an important partner in disseminating information not only to the target audience but
to the community as a whole. Sensitising and involving media, including print, audio, visual,
street plays and so on, is an important step in setting the stage for information dissemination
and initiating a dialogue on a hitherto neglected topic.
Adolescent sex education should include the following topics:
1. Knowledge of male and female reproductive systems.
2. Menstruation - It is an overt landmark which indicates that the process of ovulation
is taking place and that pregnancy may occur if the ovum is fertilised. Hence, it is
necessary to inform adolescent girls that any sexual activity can result in a pregnancy
and hence they should never allow themselves to be involved in sexual activity out
of ignorance, to avoid unwanted pregnancy.
3. Genital hygiene -In women, the external genitalia is in close proximity to the organs
of excretion. The private parts should be cleaned thoroughly while taking a bath
and also after every act of urination and defecation.
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During menstruation, only a clean, washed and sundried cloth should be used if
disposable sanitary napkins are not available. Use of dirty, unwashed pads during
menstruation can lead to itching and infection in the external genitalia.
4. Information about sexuality and responsible sexual behaviour to prevent unwanted
pregnancies and STDs.
5. Sex Education & Behaviour
Does sex education, hasten sexual activity?
In general, sex education does not
seem to cause teenagers to have sex
at an earlier age or increase their
sexual activity.
Does sex education delay sexual activity?
It may. Especially if youths receive
sex education before beginning
sexual activity, they may delay sex or
p r a c t ice
safer sex.
Does sex education lead to safer
sexual activity?
It should. Sex and AIDS
education may lead to a reduction
in the number of sexual partners
and increased use of contraceptives.
The transitions to sexual activity, marriage and motherhood are major events in a
woman's life, bringing changes in social status and responsibilities. Traditionally,
premarital sex has been discouraged in most societies, but this is now changing, and
sex among unmarried teenagers is increasingly becoming a problem in most societies.
Many adolescents find their parents and teachers ill-equipped, hesitant or afraid to
teach them on sexual issues.
The reasons for low levels of contraceptive use amongst sexually active
adolescents are:
~ Lack of information
Young people have little, inadequate or incorrect information about fertility and
contraception
~ Lack of access
Even when young adults come to know of contraceptives, few use them, as it is
more difficult for them to obtain contraceptives, than it is for older, married couples .
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They seldom visit health care providers or clinics. They do not know where to go.
Many are unable to pay for the services.
Even when young people have information about contraceptives and have access
to services, many contextual factors affect their contraceptive practices. Sex-related
issues are rarely discussed, even between spouses. Social attitudes that condemn
girls who are sexually active inhibit contraceptive use. Such attitudes increase girls'
vulnerability to STDs and pregnancy.
Adolescents, therefore, need to be informed about sexuality and responsible sexual
behaviour, to prevent unwanted pregnancies and STDs.
Sexuality and sexual development begin very early and are greatly impacted by forces
in early life. Parental attitudes, sexual education and early sexual experiences affect
sexual relationships during the life span. The sensitivity of the health provider in
education and counselling about sexuality and in early intervention in sexual dysfunction
can help in normal sexual adjustment.
Sexuality and sexual development are an integral part of a person and dealing with
roles, interactions with others and feeling about oneself as a human being. The genetic
sex of each individual is determined at conception. Biologic sex both influences and
is influenced by the cultural environment. Sex plays a critical part in determining
one's "proper" role and function in society.
Sex within a relationship demands some degree of open communication about feelings
and desires by both partners. Sexual stimulation in the adult requires a symbiosis
between the brain and the body. Each person responds according to his or her unique
physiologic and psychologic needs in a given situation. Life stresses can interfere
with aspects of the total relationship and may be reflected in difficulties with sexual
relationship. Sex is only a part of the total communication in a relationship.
Sexual expression involves more than intercourse. During the adult years, it generally
involves caring behaviours between persons. These may include a broad range of
activities from touching and petting to oral genital sex.
Sexual dysfunction is a term applied to a broad range of problems in sexual expression
and in sexual relationship. The problem may be related to the physical response or
may extend to the total communication between partners. Some of the immediate
causes of sexual dysfunction involve simple sexual ignorance and a failure of
communication of needs and desired between partners. A sexual response requires
the proper stimulation as well as the freedom to enjoy this. Fear of failure is another
common factor in sexual dysfunction. Aging has an effect both on the physical and
psychological aspects of sexuality.
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Reproductive & Child Health Care
Sexual pleasure is a part of the warmth and affection of a relationship. Although
heterosexual behaviour (sexual relationship between opposite sexes) is the most common
and socially acceptable method to achieve genital gratification, there are deviations to
this form of behaviour. Some of the more common types are mentioned below:
It is self-stimulation of the genitals in order to derive sexual pleasure and ejaculation.
Masturbation is not "abnormal" or "dirty". It may become a problem only when it
is obsessive and accompanied by personality changes.
-+ Homosexuality
This is a sexual and genital relationship between two persons of the same sex.
Bisexuals are those that have relationships with both sexes. Homosexuality can be
seen as a form of sexual behaviour, an emotional preference. There are different
schools of thought debating whether homosexuality is a disease or simply a personal
preference. In India, homosexuality is still considered a taboo. Majority of
homosexuals and lesbians (female homosexuals) in India enter into heterosexual
marriages. They normally do this because of a desire to have and raise children.
Counselling has a lot to ofTer to a person troubled with this condition.
This is a condition where a person gets sexual satisfaction by wearing clothes
belonging to the opposite sex.
This is a condition where a person gets sexual gratification by watching sexual acts
and erotic things secretly.
This is a condition where a person gets sexual gratification by exhibiting genitals
to unwilling sexual prey.
This is a sexual aberration where a person derives satisfaction by inflicting either
physical or psychological pain on his/her sexual partner.
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This is the opposite of sadism where a person gets satisfaction by getting hurt physically
or emotionally by his/her sexual partner.
Medical Termination of Pregnancy (MTP)
MTP or abortion is not a method of family planning, but it is the safest and most reliable
method of getting rid of an unwanted pregnancy.
• Legalization of MTP
MTP has been legalized by the Government of India, under the MTP Act, 1971.
It allows medical termination up to 20 weeks of pregnancy, to be carried out by trained
doctors only, in recognised health institutions.
Doctors with a postgraduate degree in Gynaecology and Obstetrics, or a Diploma in
Gynaecology and Obstetrics, having attended atleast 25 MTPs along with an experienced
doctor, are eligible to perform MTPs.
Till 12 weeks of pregnancy, MTP can be conducted by a single doctor.
Between 12-20 weeks of pregnancy, MTP can be conducted by a doctor in consultation
with another doctor.
=> If continuation of pregnancy can lead to adverse and grievous danger to the
mother's health
Facilities for conducting MTPs by trained doctors is now available in almost all
health centres and hospitals.
The woman herself can give her consent for the procedure and absolute secrecy is
maintained. In case of minors (below 18 years), and mentally ill patients, the consent
of a parent/guardian is necessary.
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• Shortcomings
In spite of making MTP legal and available, many women resort to getting abortions
done by untrained and unauthorised persons like untrained dais and quacks. It should
be realised that untrained dais and quacks use dirty sticks and needles which cause
substantial injury to the cervix and uterus and cause severe infections that may even
lead to death. In any case, they do not possess the professional competence to deal
with delicate abortion cases with medical complications.
Several unmarried adolescent girls are sexually assaulted within the family by
unscrupulous relations, or sometimes outsiders. Their timid parents often take them to
untrained persons for an abortion to maintain secrecy, with dire consequences to the
girl's reproductive health. Unsafe abortions can lead to infection, infertility and death.
It must be realised that MTP should be done only at recognised centres, by trained
doctors. It should be reiterated that all government or private centres have to maintain
absolute secrecy or anonymity of the MTP and the person. Thus, there is no reason that
the client should seek services from a dai or quack.
There is no Oral Medicine for MTP,
only Surgical Intervention
Infertility
Infertility is the inability to achieve pregnancy after unprotected intercourse within a stipulated
period of time, usually one year, or repeated failure to carry a pregnancy to term. In a country
with a population of almost one billion, does infertility matter? While childlessness may
seem like a trivial issue in a populous country, for a couple it can be a catastrophe. While
everyone around them seems to be having babies, why is it that they cannot conceive?
Contrary to general belief, infertility is not uncommon. It affects one in five couples at some
point in their lives.
Sterility is a term applied to an individual who has some absolute factor preventing conception,
even with treatment.
Primary infertility is a term used to designate those couples who have never conceived, whereas
secondary infertility indicates that atleast one conception has occurred for one or both, but that
the couple is currently not able to achieve pregnancy.
Medically, infertility is a condition where two individuals must be considered, as either one of
them or both may be factors contributing to the condition .
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The most common causes of infertility in men are:
~ reduced production of sperms, or the sperms are not mobile enough and cannot
swim to the woman's fallopian tubes to fertilize the ovum (egg)
~ history of mumps after puberty. Mumps can affect the testes, thereby affecting the
formation of sperms. In some cases, the ejaculate may be completely devoid of
sperms (azoospermia)
~ occulusion of the vas deferens, caused by scarring due to past or present sexually
transmitted infections. The sperms cannot be transported upto the urethra.
~ swelling of the veins of the scrotum (varicocoele)
~ problems during sexual intercourse
.:. penis does not harden
.:. penis hardens, but does not stay hard long enough
~ Exposure to toxic chemicals (in factories) or pesticides decrease the production of
sperms
~ High temperatures - A man's sperms need to stay cool. That is why the testes hang
in the scrotum, outside a man's body. If the testes become too warm, sperm production
is hampered. This can happen if a man wears tight clothes that press his testes up
inside his body (eg. very tight jeans), or works near hot boilers or furnaces
~ Certain drugs affect the formation of sperms
.:. Absence of ovulation. This could be due to insufficient levels of hormones in
the body
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.:. Smoking, drinking alcohol and chewing tobacco would affect the production
of ova.
Advice to be given to couples who think that they are infertile:
~ Try to have sexual intercourse during ovulation, i.e. during midcycle.
~ During sexual intercourse, the best positions to ensure that sperms enter the
uterus are:
• woman lying on her side
After sex, the woman should lie flat on her back for atleast 20 minutes .
•:. do not use oils or creams during sex. They can kill the sperms and/or make
sperm entry difficult
.:. do not wash (douche) inside the vagina immediately after sex
.:. do not have a hot bath just before sex. Heat on the testes may kill
the sperms
~ Treat health problems, including STDs
~ Practice good health habits, i.e. eat healthy foods, avoid smoking and drinking alcohol,
avoid caffeine and get plenty of rest and exercise
~ Visit a doctor if unable to get pregnant after one year
Infertility can make a couple sad, frustrated or angry. They should, therefore, be treated kindly
and sympathetically. Proper counselling on life style, habits and sexual intercourse can
sometimes lead to pregnancies. If, however, a couple is still unable to achieve pregnancy
after a year of trying, they should jointly be taken to a doctor.
Myth
Reality
Myth
Reality
Myths and Realities
Infertility is always due to the woman
A man or woman can be equally infertile
By offering prayers, infertility can be treated
Only proper check up, diagnosis and treatment
of the cause of infertility can relieve the problem
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The breasts of fatty tissue with milk producing glands. They start growing in size at puberty
and start producing milk after child birth. The breasts are very sensitive to touch and can play
an important part in sexual arousal.
However, like any other organ in the body, diseases of the breast are not common. Some of the
more common problems of the breast are mentioned below:
• Breast Lumps
Breast lumps are usually soft and can change in size during the course of a menstrual
cycle. They may sometimes be sore or painful. Not all breast lumps are cancer, but
since it is always a possibility, a woman should try to examine her breasts once a
month.
• Discharge from the nipple
Milky or clear discharge from one or both nipples is usually normal, if a woman has
breast fed a baby within the last year.
Breast feeding mothers may develop an abscess (mastitis), which is a hot, red sore area
on the breast. This is caused due to infection in the breast tissue. The woman should
immediately be referred to a doctor for treatment.
A malignant tumour is called a cancer. The cancer usually starts as a small nodule, in
one of the breasts, gradually enlarges and then gets disseminated to other organs like
bones, lungs, liver and the brain. In advanced stages, it is difficult to treat, hence, the
nodule should be detected as early as possible and surgically removed. Women should
thus learn to examine and palpate their own breasts to identify such nodules early.
• Warning Signs
~ A hard painless lump, with a jagged shape, in only one breast and does not move
under the skin
~ Redness or a sore on the breast that does not heal
~ Skin on the breast looks rough or pitted, like orange or lemon peel.
~ Abnormal discharge from the nipple
~ Painful swelling under the arm (sometimes)
~ Pain in the breast (rarely)
A woman having one of more of these complaints should immediately be referred to the nearest
specialised health facility.
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Menopause
Menopause is the stoppage of menstruation, marking the end of a woman's reproductive life.
It usually happens between the ages of 45 and 55. Menstruation may stop suddenly, or gradually
over I to 2 years. Menopause happens due to a reduction in female sex hormones. Ovulation
stops, the uterus and ovaries atrophy. Because of a reduction in sex hormones some women
experience hot flushes on the face, depression and emotional instability. These symptoms
occur in various forms and intensity in different women and most women get through it without
any treatment.
Due to a reduction in the level of oestrogen in the body, there is loss of calcium from the bones,
leading to fractures. There is also a predisposition towards coronary heart diseases. Aging of
the skin and appearance of wrinkles on the face and neck are accelerated after menopause.
• Signs of Menopause
=> Monthly bleeding pattern changes
=> Hot flashes (suddenly feeling hot and sweaty)
=> Vagina becomes less wet
=> Mood swings.
If a woman's symptoms of menopause are so severe that they stop her from doing her daily
work, or keep her from sleeping at night, she may be given "hormone replacement therapy" or
HRT, under supervision of a doctor. HRT is oestrogen and progesterone, given to minimize
the discomforts associated with menopause. Most women, however, do not need medicines.
Counselling and family support are usually enough to help a woman through menopause.
Reproductive Tract Infections (RTls) including STDs
and HIVIAIDS
Reproductive Tract Infections (RTIs) are infections ofthe reproductive organs. They are caused
by different organisms/germs. They may be mild and prolonged and may result in chronic
lower abdominal pain, backache, dysmenorrhoea (pain during menstruation) and vaginal
discharge.
Some of the RTIs spread through sexual contact from the man to the woman and vice versa.
These are called sexually transmitted diseases (STDs) ..
The reproductive tract can get infected because of:
=> poor general health
=> poor genital hygiene
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~ sexual intercourse with an infected person
~ trauma (eg. from delivery, sexual intercourse, use of chemicals, etc.)
~ unhygienic practices during deliveries, abortions, IUCD insertion, etc.
1. Wash in Plain
water
-
(~.h.~.
(Jd y/ " ":,t--
~:.:::.",.
4. Store in a clean
place with neem
leaves
RTls are more common in women because of their body structure and functions (eg.
menstruation, pregnancy, child birth) being much more vulnerable to the entry and
growth of germs.
The signs and symptoms of RTls/STDs are:
• In women
~ foul smelling and/or excessive vaginal discharge
~ pain in the lower abdomen
~ sores/blisters over the external genitalia
~ swollen or painful lymph glands in the groin
~ pain or bleeding during sexual intercourse
~ pain or burning during urination
~ itching around the genitals
~ changes in the quantity of menstrual bleeding
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~ discharge from the penis
~ swollen or painful lymph glands in the groin
~ difficulty and pain during urination
~ pain during intercourse
~ scrotal swelling
~ by having one faithful sexual partner
~ treating STDs in both the partners
~ using condoms (men) and spermicides (women)
~ avoiding sexual intercourse if any of the signs of infection are present.
• Complications of untreated RTIs/STDs
~ pregnancy-related complications like abortion, still births or birth defects.
~ during delivery, the newborn can get eye infection from the mothers' birth canal.
This may lead to blindness
AIDS is a fatal and dangerous disease which is caused by a virus called human immuno-
deficiency virus (HIV) .
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ReproductivSeystemAndReproductivHeealth
This virus (HIV) destroy~ the white blood cells present in our blood, which protect us
from infections and help us to fight diseases. As a result, people infected with HIV are
easily affected by diseases like tuberculosis, diarrhoea, pneumonia, etc. Repeated
infections lead to emaciation and death. After entering the body, the virus gradually
multiplies in the body and may take 8-10 years to completely destroy the body's defence
mechanism (immune system). During this silent period the virus can spread to
other persons.
Remember
There is no treatm.~~tI(!r _1}J)§
AIDS Virus
Attacks
Body Soldiers
Killed Other Germs
Invade Body
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• Spread of HIV
HIV /AIDS is spread by:
=> unprotected sexual intercourse with an infected person
=> blood transfusion from an infected person.
=> using needles/syringes contaminated with the virus from an infected
=> from an infected mother to the foetus, through the placenta.
person
Unprotected sexual intercourse
with an in fected person
From an infected mother to
her unborn child
Blood transfusion from
an in fected person
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• HIV/ AIDS is not spread by
=> mosquito bites
=> hugging and touching
=> sharing food and utensils
=> shaking or holding hands
=> looking after an infected person
=> working or playing together
=> sharing toilets
=> coughing of sneezing
=> being in company with oth!er
=> people in a crowd
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.'\\1 DS can be suspected if a person has one or more of the l()l!owing symptoms:
=> persistent cough I()I" more than a month not rdated to smoking or other causes
~ itchv skin rashes
.=.> cold sores allover the body
=> recurrent herpes zoster (shingles)
'. s\\\\ollen lymph glands
loss or \\Veight (more than loo'il)
..~ persistent fever lor more than a month
...:::-persistent severe fatigue
:c:. persistent diarrhoea lor more than a month
::.-:> severe night sweats
• Prevention/Protection from AIDS
People can pro!l:ct themselves li"ntH AIDS by the 1()llowing measures:
::::> practicing safe sex. i.e. using a condom during every sexual contact
-:C.' avoiding in.iections \\vith contaminated needles
=> testing blood for IllY (by blood banks)
'.-. avoiding/terminating pregnancy if a woman is suffering from the disease
PREVENT HI VIAIDS
A
A b.\\"tillelcl e
B
Be FlIit/~flll
C
COllsiste"t~v Use Comlom
D
DOII't U\\"eUllsterile Needles
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Questions
4. Fertilization takes place in the
5. Tick the male hormone:
(b) women
10. How are STDs spread '?
1I . Hmv can STDs be prevented?
12. What is the difference between HIV and AIDS?
13. How is HIV spread?
14. How can people protect themselves against HIV infection?
16. What do you understand by MTP and who is competent to do it?
17. Give the treatment for AIDS.
19. What are the main reasons for lack of contraceptive use among
adolescents'?
20. What are the changes that an ovum undergoes in the female reproductive system
after fertilization?
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9.2 Page 82 |
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• Is there any puckering or dimpling or
change in skin texture'?
Raise your hands ahove your head
and inspect your hreasts:
• Is there any swelling or skin puckering?
Lower and raise your anTISwhile
watching your nipples:
• do they move the same distance?
• change in outline
• puckering
/
/
~
============::====::=::::==::::::=~@!:=::::=::=::::=::==::=::==::==MOdule-3
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4. Lying down start with one breast. Use the Hat of your hand to feel for any lumps.
thick or bumpy areas. Don't press too hard or too lightly. Repeat on the other side.
--
)
5. Slide your hand over one breast above the nipple starting at the armpit. moving
il1\\vards. Feel for lumps. Keep moving your hand across the nipple till you have Ielt
all parts of the breast. Repeat on the other side.
6. Feel for lumps along the top of the collar bone and in the armpit on one side.
Repeat on the other side.
If any abnormality is detected. please consult a doctor.
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REPRODUCTIVE AND CHILD HEALTH SERVICES
._CTIOIIS
1. Evolution of RCH Programmes
2. (A) Safe Motherhood
(6) Care of Infants &.. Children
rJr' Learning Objectives
• Understand the concept ofRCH and the historical events leading to the evolution
of this concept
• List out the components of RCH
• Identify the service delivery components under RCH
~ Teaching Aids
=========================::f(DI=================----.=Module-4
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BECTIO,,~1
Introduction
The Reproductive and Child Health Programme addresses the reproductive needs of men,
women and children during their entire life cycle. There is a need to specially focus on women
since they constitute the major client group or users of the programme and also have the greatest
problems of access to health services, both physical and social. Women's health is important
during all phases of their lives, from childhood to adulthood and also because they have to
bear the major brunt of the process of reproduction. Good health is cyclical in nature. In a
woman's life time, her health status during any phase of life impinges upon the next phase.
When she gives birth, she passes on the gift of good health to the next generation. A healthy
child grows up into a healthy adolescent; good health during adolescent years leads to health
during reproductive years; the cycle continues into the next generation when a healthy
pregnancy ensures a healthy child. After the reproductive years, women face health problems
during menopause that also need to be addressed in order to ensure a good quality of life. If
implemented in an integrated manner, the RCH programme will go a long w"ay towards
improving the overall health of women in particular and that of society as a whole.
The National Family Planning Programme was started in 1951 as a purely demographic
programme. Subsequently, the element of health/population education and extension was
included to derive better results. During the 1970s, the family planning programme focussed
mainly on terminal methods and the programme received a setback due to rigid implementation
of a target-based approach.
The experiences gained showed that people did not respond to the programme as enthusiastically
as expected, because of several reasons. A key reason was that they were not sure if children
born to them would survive and be healthy. To address this problem, the Government ofIndia
launched several successful initiatives to reduce child mortality. During 1984-1989 (Seventh
Plan), Family Welfare Programmes were evolved with the focus on the health needs of
women in the reproductive age group and of children below the age of 5 years. The main
objective of the Family Welfare Programme for the country has been to stabilise population at
a level consistent with the needs of national development.
.l.ttt.l.PFI=======~0-------------------------------~---------
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The Universal Immunisation Programme (UIP), aimed at reducing mortality and morbidity
among infants and younger children due to vaccine preventable diseases, was started in 1985-
86. The Oral Rehydration Therapy (aRT) was started in view of the fact that diarrhoea was
a leading cause of death among children. Various other programmes under Maternal and
Child Health (MCH) were also implemented during the 7th Plan. The objectives of all these
programmes were convergent and aimed at improving the health of mothers and young children
and providing them facilities for prevention and treatment of major disease conditions. While
these programmes had a beneficial impact, the separate identity of each programme was causing
problems in its effective management. Therefore, in the 1990s (8th Plan), these programmes
were integrated under the Child Survival & Safe Motherhood (CSSM) Programme which
was implemented from 1992-93.
The process of integration of related programmes, initiated with the implementation of the
CSSM Programme, was taken a step further in 1994 when the International Conference on
Population and Development in Cairo stated that the participant countries should implement
uniform programmes for Reproductive Health (RH). In the RH approach, "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 well-being and couples are able to have sexual relations
free of fear of pregnancy and of contracting diseases."
During the 9th Plan, the Government of India integrated all the related programmes of the 8th
Plan with the Reproductive Health (RH) approach, thus initiating the Reproductive & Child
Health (RCH) programme. The concept of RCH is to provide need-based, client centred,
demand driven, high quality and integrated RCH services to the beneficiaries. RCH is more
relevant to the objective of stabilization of the population of the country.
Family
Planning
Programme
Maternal
and
Child
Health
Programme
Safe Motherhood
and
Child Survival
Programme
Reproductive
and Child
Health
Programme
The RCH programme incorporates the components related to the CSSM programme and
includes additional components relating to Sexually Transmitted Diseases (STD), Reproductive
Tract Infections (RTI) and adolescent reproductive health.
--------------0!:=:====================Module-4
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Reproductive & Child Health Care
Achievements
Indicator
Past Level
Current Level
IMRI
CDR
MMR
TFR
146 (1951-61)
25.1 (1951)
NA
6.1 (1951)
72
(1996)
9.2 (1994)
4 (1992-93)
3.5 (1993)
Life Expectancy at Birth
(Years)
Male
37.1 (1951)
Female
36.1 (1951)
CBR
40.8 (1951)
Effective CPR
10.4 (1970-71)
Immunization Status
(% coverage)
TT (Pregnant women) 40 (1985-86)
BCG (infants)
29 (1985-86)
Measles (infants)
44 (1987-88)
61.5
62.1
27.4
46.5
76.7
83.69
78.9
I
(1996)
(1996)
(1996)
(1996)
(1996)
(1996)
(1996
• IMR - Infant Mortality Rate;
• MMR - Maternal Mortality Rate;
• CBR - Crude Birth Rate;
• IT - Tetanus Toxoid
• CDR - Crude Death Rate;
• TFR - Total Fertility Rate;
• CPR - Couple Protection Rate;
Goals by
2000AD
< 60
9
2
2.3
64
64
21
60
100
85
85
.I.tlt.l.PF1================0J===========
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9.9 Page 89 |
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Reproductive and Child Health Services
OLD FAMILY WELFARE
APPROACH
• No Counselling
• Emphasis on terminal methods
• Referral system only on paper
• Not user friendly
• Top down
• Target free (Self estimated goals by
health workers)
• Counselling
• Emphasis on spacing method
• Functional referral system
• User friendly
• Bottom up
NATIONAL
LEVEL
STATE
LEVEL
DISTRICT
LEVEL
PRIMARY
HEALTH
CENTRE
J, Set Target
Accept
Target
~
Break down
Targets
J,
Distribute
J,Targets
Implement
Target
STATE
LEVEL
DISTRICT
LEVEL
PRIMARY
HEALTH
CENTRE
SUB
CENTRE
Strategies&
Computations
t
Report Results
t
Support&monitor
Implementation
t
Facilitate
Implementation
t
Set Goals
Participate in
Goal Setting
==============:=f0J============Module-4
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RCH Packages for Target Groups
=> All pregnancies have to be registered by medical or paramedical staff within
12 weeks.
=> Pregnant women must be given Iron Folic Acid tablets for prevention and for
treatment in case she is anaemic.
=> Pregnant women must be given minimum 3 antenatal check-ups which should
include checking their blood pressure (BP) and detecting complications.
=> Deliveries by trained personnel in safe and hygienic surroundings must be ensured.
=> Institutional deliveries should be encouraged for women having complications.
=> Referrals should be made to identified First Referral Units (FRU) for management
of obstetric emergencies.
=> A minimum of three post-natal check-ups should be given to mothers after the
delivery.
=> Spacing of atleast 3 years between children must be encouraged.
=> Essential new born care like keeping the baby warm, checking the baby's weight
and giving the baby mother's milk is important. Babies that are premature or have
low birth weight should be provided special care. Babies with any complication
should be referred to the Health Centre.
=> Exclusive breast feeding must be ensured for the first 3 months. Weaning should
be started in the fourth month.
=> BCG, DPT , Polio and Measles vaccine should be administered according to
schedule to every child meticulously to prevent death and disabilities.
=> Vitamin-A prophylaxis for children should be ensured to prevent blindness.
=> Parents must be informed about oral rehydration therapy and correct management
of diarrhoea.
=> Acute respiratory infections in children should be detected early. If necessary,
they should be referred to health centres.
=> Treatment of anaemia .
.•t.tt.l.PF1 ===============~0J:::===========
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~ Treatment of anaemia.
~ Promoting use of contraceptive methods among eligible couples is important to
prevent unwanted pregnancies. Couples should be able to choose from various
contraceptive methods.
~ Safe services for medical termination of pregnancy should be ensured for women
desiring abortions .
•:. Safe services for medical termination of pregnancy should be ensured for women
desiring abortions .
•:. A large number of people suffer in silence due to Reproductive Tract Infections
(RTIs)/Sexually Transmitted Diseases (STDs). RTIs/STDs can make people
infertile. If a pregnant woman has RTIs or STDs, it can affect the health of her
child. People suffering from such infections should be treated immediately .
•:. Adolescents are parents of tomorrow. It is important to prepare them for the future
by counselling them on family life and reproductive health. This can be a sensitive
topic as it has not been addressed before.
FAMILY
PLANN;NO
ADOLESCENT
EDUCATION
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Involving men in the Reproductive and Child
Health Programme
Men, as well as women, play key roles in reproductive health, including family planning.
Men can help protect the lives and health of women as they become mothers and can attend to
the health of their children. Their decisions and actions often make the difference between
illness and health, life and death.
Family planning programmes have always avoided men, assuming that men are indifferent or
even opposed to family planning. Men are a diverse group of individuals. They reflect the
spectrum of humanity, from kind and caring to abusive and dangerous. It is, therefore, important
that health programmes abandon stereotypes of men and learn about their concerns and needs.
Male involvement in RCH goes beyond increasing the use of condoms or vasectomy. It must
be recognized that:
• Men play important, often dominant roles in decisions crucial to women's
reproductive health
• Men are more interested in family planning than often assumed, but need communication
and services directed specifically to them
• Understanding - and influencing - the balance of power between men and women can
help improve reproductive health behaviour
• Couples who talk to each other about family planning and RCH can reach better,
healthier decisions
Men's participation is a promising strategy for addressing the most pressing reproductive health
problems. However, it involves a complex process of social and behavioural change that is
needed for men to play more responsible roles in RCH.
The roles that men may play in the RCH programme, are:
• planning their families
.a.(t"LPFI =======::r.0~==========-=--=--=-"=-"=-"=-===
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The question today is no longer whether to involve men, but how to involve them. Men's
participation has to be incorporated into the design and implementation of RCH programmes.
The following give a broad outline on how to involve men in RCH programmes. However,
the concept is discussed in detail in Module VII.
• Reach male audiences with appropriate messages
=> Build on men's approval of RCH including family planning
• Use communication to promote behavioural change
=> Understand the influence of gender
=> Encourage couple communication
=> Bring information to where men gather
=> Inform men about RCH including family planning
=> Counsel men with respect and sensitivity
=> Offer men a range of health services.
=======~=====================::0~=====~=============~MOdule-4
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r:iF Learning Objectives
• Identify the signs and symptoms of pregnancy, in each trimester.
• Identify the complications and the danger signs in pregnancy.
• Understand the management of labour and its complications.
• Describe postnatal care and its complications.
• Describe normal child development.
• Describe the importance of immunization during childhood and pregnancy.
~ Teaching Aids
• Flip charts
• Sketch pens
• Slides
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10.5 Page 95 |
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(A) SAFE MOTHERHOOD
Introduction
Maternity care has two closely related goals - promoting maternal health and preventing
maternal death. Good "maternal health" means that pregnant women and mothers with newborn
babies are well-nourished, free from infections and diseases and are under treatment for chronic
treatable diseases, when necessary. Even with such care, pregnant women who are healthy
may experience obstetric complications, which may be catastrophic if left untreated. Preventing
maternal death means that those who have complications during pregnancy or delivery be
appropriately managed. Making quality family planning services readily available and
accessible also helps to prevent maternal deaths.
In India, about 450 mothers out of every 1,00,000 births die during pregnancy or childbirth as
compared to less than 10 in 1,00,000 in developed countries. This indicates that the health of
the woman during pregnancy, during delivery or after delivery is neglected. A mother's death
is a profound loss not only to the newborn and young children, but to the entire family.
Simple and timely precautions, adequate nutrition, frequent health check-ups and delivery
conducted by trained personnel or in an institution can prevent maternal deaths and ensure a
safe motherhood.
Life-cycle Approach For A Female
Victims of abortions, infanticide, etc. If they survive,
they are breastfed for a shorter period than
male babies. Utilisation of hospital services
is less for female babies.
.L Old woman
T
Female baby
1
Growing Child
Menopausal problems,
malignancies, neglect,
marginalisation, dependency
Young woman
1
Early marriage and
early and repeated
pregnancies
Less nutrition
Less access to food
& health care
Young adolescent
1
Start work early,
longer & harder.
Anaemic because of
inadequate nutrition not
compensating menstrual
blood loss
~~~~~~~~==~~==~===~~==~~==~=::'@:=====================MOdule-4
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The Major Components of Safe Motherhood
FAMILY
PLANNING
I
I
ANTE
NATAL
CARE
CLEAN
&
SAFE
DELIVERY
BASIC
MATERNITY
CARE
ESSENTIAL
OBSTETRIC
CARE
PRIMARY HEALTH CARE
I
GENDER EQUITY
I
Maternal and Child Health
Mothers and children constitute approximately 60% of the population in developing countries.
They not only constitute a large group, but are also a "vulnerable" or special-risk group, because
of interdependence between them.
• During the antenatal period of 40 weeks, the foetus is dependant on the mother for its
nutrition and oxygen.
• Child health is closely related to maternal health'- a healthy mother gives birth to a
healthy baby.
• If a woman has German measles or Syphilis during pregnancy, it can affect the foetus,
giving rise to congenital malformations.
• After birth, the newborn is solely dependant on the mother's breast milk for nutrition.
• The mother is also the child's first teacher - for both mental and social development.
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The conventional term "Maternal & Child Health" refers to the promotive, preventive, curative
and rehabilitative health care of mothers and children. Maternal health care includes:
• Antenatal Care (ANC)
• Intranatal Care (INC)
• Postnatal care (PNC)
Before going into the details of care to be given to a pregnant woman during and after her
pregnancy and delivery, one should know about the sequence of events and changes that take
place in a woman's body during this period.
Diagnosis of Pregnancy
As mentioned in Module ITI, the reproductive period of a woman begins at menarche and ends
at menopause. It usually extends from 10 to 49 years of age. The duration of pregnancy is
calculated in terms of 40 weeks, or 280 days, or 9 months and 7 days, calculated from the first
day of the last menstrual period (L.M.P.). For example, if a woman started her last menstrual
period on 7th June, 1998, her expected date of delivery (E.D.D.) is 9 months and 7 days later,
i.e. her E.D.D. is 14th March 1999.
Pregnancy is divided into three stages, or trimesters, each covering a period of
13 weeks (approx. 3 months).
First Trimester of Pregnancy (0 - 13 weeks)
• Signs & Symptoms
~ Stoppage of menstruation
~ Morning sickness - nausea and vomiting
~ Increased frequency of urination
~ Breast discomfort, with enlargement and darkening of the nipples
~ Fatigue.
Second Trimester of Pregnancy (14 weeks - 27 weeks)
• Signs & Symptoms
~ The uterus can be felt through the abdomen.
~ Foetal movements can be felt by the mother.
===========================@_--------------------- _-_-_-_-_-_-_-_-_-_-Module-4
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Third Trimester of Pregnancy (28 weeks - 40 weeks)
• Signs & Symptoms
=> Further enlargement of the abdomen.
=> Foetal parts can be felt through the abdomen.
=> Breast changes and foetal movements are more pronounced.
=> Frequent urination.
-+ The common discomforts of pregnancy are:
.:. Morning sickness (feeling of nausea and vomiting on waking up in
the morning)
.:. Frequent urination
.:. Constipation
.:. Heartburn
.:. Backache
.:. Shortness of breath .
A Pregnant Woman needs
• enough rest, sleep and relaxation
• good personal hygiene
• comfortable clothing and footwear
• emotional support
• regular antenatal check-ups, iron folic acid tablets and 2 doses of tetanus toxoid injection.
Nutrition during Pregnancy
A pregnant woman should eat enough food for herself and her growing baby. Dietary advice
should be given with due consideration to the socio-economic condition, food habits, locally
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10.9 Page 99 |
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available food ingredients and taste of the individual. Health workers must be very sensitive
to these factors while giving nutritional advice.
The total average weight gain during course of singleton pregnancy is 11 Kg-12 Kg. This
weight gain is not uniform throughout pregnancy, but varies during the different trimesters:
1st trimester
IInd trimester
IIIrd trimester
tKg
5 Kg
5Kg
I Reproductivwe eightgain
Baby or foetus
3Kg
Placenta
0.5 Kg
Uterus+Amniotic fluid
+Breast
2.5 Kg
II Maternalweightgainin theform of
- Fat, increased blood volume, fluid
================r@e==========Module-4
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10.10 Page 100 |
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Antenatal Care
Antenatal care is the care given to a pregnant woman during her pregnancy.
The objective of antenatal care is to assure that every wanted pregnancy culminates in the
delivery of a healthy baby without impairing the health of the mother. This is done by -
• promoting, protecting and maintaining the health of the mother and foetus during
pregnancy
• foreseeing complications and preventing them
• removing the dread and anxiety associated with delivery
• taking steps to minimise maternal and infant mortality and morbidity
• teaching the mother elements of child care, nutrition, personal hygiene and
environmental sanitation
• sensitizing the mother to the need of family planning
Ideally, a pregnant woman should attend the antenatal clinic once a month during the first
7 months, twice a month during the next 2 months, and thereafter, once a week, till delivery. A
large number of women, however, cannot attend the clinic so frequently. In these cases, a
minimum of three visits is advised.
• 1st visit at or before 20 weeks or as soon as pregnancy is confirmed
• 2nd visit at 32 weeks
• 3rd visit at 36 weeks.
At each visit, a check-up of blood, urine, blood pressure and weight should be done. Two
injections of tetanus toxoid should be given, starting at 5 months, at an interval of one month.
However, the second injection should be given at least one month before the Expected Date of
Delivery. Since, during prgnancy, dietetic iron is not enough to meet the increased requirement,
one tablet of iron and folic acid should be taken daily, as a supplement, during the latter half of
second trimester and early third trimester, for atleast 100 days. No drugs should be taken
during the first trimester of pregnancy, unless prescribed by a qualified physician.
• Smoking & drinking during pregnancy
Smoking (including passive smoking) and drinking of alcohol can cause birth defects.
Both should be avoided during pregnancy. Certain drugs are also harmful for the
foetus and therefore medication should be avoided as far as possible .. A doctor's advice
should always be sought before any medication is started.
:!: • High Risk Pregnancy
It is broadly defined as a pregnancy in which there is or will be an increased risk of
morbidity or mortality of the mother, foetus or new born, before or after delivery.
Some of the high risk factors are:
.l.tt\\'PFI================:!@r::==========
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11.1 Page 101 |
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• maternal age (below 20 years and above 35 years)
• history of two or more previous abortion/still births/low birth weight babies
• history of 3 or more previous pregnancies
• history of previous Caesarean section or uterine surgery
• previous pregnancy less than 2 years ago
• bleeding during present pregnancy
• medical illness (hypertension, diabetes, jaundice, etc.)
• height below 145 em
• weight below 45 kg or above 80 kg
• high blood pressure with severe headaches, giddiness, dimness of vision
• massive swelling of the feet
• uterine size - disproportionately large (could be multiple foetuses) or small (small
for date/birth defects, etc.)
High risk cases should be identified at the earliest and should be referred to trained
medical personnel.
• Complications during Pregnancy
Complications can suddenly arise anytime during pregnancy. These may be life
threatening and may need immediate medical attention. These serious complications
can be recognised by the following danger signs:
=> vaginal bleeding - can be due to abortion or antepartum haemorrhage.
=> swelling of the face/hands - due to anemia or increased blood pressure.
=> blurring of vision - due to increased blood pressure.
=> severe headaches - due to increased blood pressure
=> severe pain in the abdomen - due to abdominal infection or ectopic pregnancy.
=> persistent vomiting - due to raised hormonal level.
=> high fever - suggestive of infection.
=> discharge of fluid from the vagina - due to infection in the reproductive tract
Though any pregnant woman can suffer from any or some of these complications any time
during her pregnancy, they are much more common in women who have high risk pregnancies.
Early detection of complications and immediate medical attention is essential in these cases.
:::::::::::::::=:::======:::==::::::=:::=::::::===~®:::==========:::========= Module-4
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11.2 Page 102 |
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Sexual Intercourse during Pregnancy
There is general agreement that in a normal pregnancy (i.e. without complications), sexual
intercourse is considered safe and most couples can continue intercourse until shortly before
birth. However, if there is threatened miscarriage or premature labour or bleeding, sex should
be avoided.
.,~
t~
ft;
c'
; \\ , . \\.,
i 1\\ \\
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I.)' fri::'!' .~\\I) .
I
0,
j ; ;", ./"
\\1 ~?
'\\ '1:"":';('
1/'/~'·,;U~ I ~II.I •.._•.. :
l1~
~
(00
ao
'0
.._- 40
.~
|
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11.3 Page 103 |
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Intranatal Care
It is the care given to the mother during delivery. In India, majority of births take place at
home.
Childbirth is a normal physiological process. However, complications often arise. The aim of
good intranatal care is to conduct the delivery in conditions where there is no infection, with
minimum injury to the mother and the infant and lastly prevention, early detection and
management of complications of delivery.
============================®=====================MOdule-4
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11.4 Page 104 |
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The unborn baby comes out of the mother's body by a process called" labour". During labour,
the uterus contracts at regular intervals so that the mouth of the uterus (cervix) opens up (Stage
I) and the bag of water breaks, allowing the baby to come out of the uterus and pass out of the
mother's body through the vagina (Stage II). In primigravida (first pregnancy), Stage-I takes
around 12 hours. In subsequent pregnancies, the process takes 6-12 hours. After birth of the
baby (within 5 minutes to Y2 an hour), the placenta comes out with a gush of blood (Stage III).
Once the uterus is empty, it contracts immediately, thus controlling the blood loss. After the
baby is born, the umbilical cord has to be tied and cut. The umbilical cord is tied 3 cm to 5 cm
from the infant's abdomen. The cord is cut with a new sterile blade between these ties.
Labour or the complete process of delivery of the foetus and after- births can be divided into
three stages and the duration of each of these stages is given below.
Stages
Stage I
Stage II
Stage III
Stages of labour
Time Required
Primigravida
(lst Pregnancy)
Multigravida
(Subsequent
Pregnancies)
Starts from onset of true
labour pains and ends with
full dilatation of Cervix
12 hrs
6 hrs.
Starts from full dilatation
of Cervix and ends with
expulsion of the foetus
Starts from expulsion of
foetus and ends with
expulsion of placenta
1 hr
30 minutes
30 minutes
5-10 minutes
.I.+t\\PFI=~~~~~~~~~=~~®------------------:---------
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11.5 Page 105 |
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A Normal Delivery
==========================~®:====================~MOdule-4
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11.6 Page 106 |
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Reproductive & Child Health Care
/"/~..~..;... \\
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..
• How to prepare for a safe home delivery
~ Contact and book a trained birth attendant.
~ Select a clean, dry, well-ventilated room for delivery.
~ Keep a home delivery kit ready
(consists of a clean bed sheet or plastic sheet, a cake of soap, a new blade, a clean
thread to tie the cord).
The FIVE CLEANs to be practiced
during delivery are:
~ Clean delivery surface (bed
sheet/plastic sheet)
~ Clean hands (of the birth
attendant and assistant)
~ Clean thread
the Cord)
(to tie
~ Clean blade
the Cord)
(to cut
~ Clean cord stump (nothing
is to be applied on it) .
.•t.tf.l.PF1 ====-=-'=-"'=--=--=--=--=----------@!::====================
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11.7 Page 107 |
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:!: • Danger signs during delivery
Sometimes, inspite of an uneventful antenatal period, problems may suddenly arise at
the time of delivery. These problems may be:
~ Sluggish or no labour pain after rupture of the membranes. Alternatively, there
may be severe contractions lasting for more than 12 hours, without the baby being
delivered
~ No progress after rupture of the membranes
~ Prolapse of cord or hand or foot
~ Slow/fast/irregular foetal heart sounds
~ Severe headache or visual disturbances or convulsions
~ Collapse during delivery
~ High fever
~ Meconium (green/brown/yellow fluid) seen after rupture of the membrane
~ Placenta not separated within half an hour after delivery
~ Excessive bleeding during or immediately after delivery.
These danger signs require immediate attention and intervention (including surgical) and it is
advisable to transfer the mother to the nearest health facility.
Post Natal Care (Care after delivery)
The period of 6 weeks or 42 days following delivery is known as the post-partum period
during which the woman's body returns to its normal state and gets adjusted to the new way of
life with the new born. This is the period of rest and recovery after pregnancy and child birth.
The following changes occur in the woman during the post-partum period.
~ Uterus shrinks
~ Cervix closes
~ Vagina and abdomen return to normal size
~ Breasts begin to produce milk.
~ Depression
~ Frequent shifts in mood.
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Lochia is the fluid that comes out from the uterus after delivery. It is bright red in colour for a
few days immediately after delivery, as it mostly contains blood. Gradually, its colour changes
to dark brown and then pale cream. The amount of discharge becomes smaller over time and
then completely stops, usually by the end of the fourth week.
/
~
The needs of a woman during the post-partum period are:
• Rest - to recuperate and become normal and healthy again
• Emotional Support - to adjust to her new role of being a mother
• Cleanliness - as she is prone to infections during this period, daily baths and the
use of clean sanitary napkins are mandatory
• Resuming intercourse - should be done after the lochia has ceased to flow and
she is comfortable doing so
• Diet - Should be the same as that during pregnancy. If she is breast-feeding the
baby, she should be sure to drink plenty of fluids, milk and body-building foods
• Iron & Folic Acid - should be taken as long as she is breast-feeding
• Health Check-up - at least 3 check-ups (after 24 hrs, I week & 6 weeks) are
necessary during the post partum period to ensure that there is no problem and also
to give her advice on child care and contraception .
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• Complications following delivery
Serious complications may sometimes occur following delivery. They are:
=> Haemorrhage or heavy bleeding
=> Infection/sepsis
These complications can be recognised by the following signs/symptoms:
=> Convulsions/fainting attacks
=> Heavy bleeding
=> High fever
=> Severe pain in the abdomen-
=> Foul smelling discharge from the vagina
=> Vomiting or diarrhoea
Should any of the above signs/symptoms be seen, the woman should be shifted immediately to
the nearest health facility for prompt medical attention.
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Reproductive & Child Health Care
A high maternal mortality rate reflects the depressing condition Of health services as also the
chronic neglect of women. Ironically, most of these deaths are preventable.
Strategies to reduce maternal mortality:
A. Access to trained birth attendants
B. Effective referral system
C. Women's empowerment
All pregnant women are at risk of developing obstetric complications and unless they have
access to Emergency Obstetric Care (EOC), maternal deaths cannot be substantially reduced .
•:. Transport and Funds
.:. Know ledge of EOe location
Ability to identify emergencies and refer
.:. Drugs to control bleeding, convulsions, infections
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12.1 Page 111 |
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1 DELAY in deciding to seek medical care
Factors that contribute to the delay in deciding could be
• the low economic status of the family
• the low educational status of the family
• the low value placed on a woman's life
• not recognising the danger signals in time
2 DELAY in reaching a medicalfacility with adequate care
Factors that might delay people from getting to a hospital could be
• the distance from the PHC
• lack of proper transport
• poor roads
• the high cost of getting there
3 DELAY in receiving quality care at the facility
• lack of emergency obstetric care facilities.
==========================~®======~~":.":.":."=-"=-"!.."!.."!.."':..-_-_~-Module-4
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(8) CARE OF INFANTS &.. CHILDREN
1. Infancy (upto 1 year of age)
• Neonatal period - (first 28 days of life)
• Post Neonatal period - (29th day to 1 year of age)
2. Pre School age ( 1-4 years)
3. School age (5-14 years)
Most of the infant deaths occur in the first month of life. The care of the child immediately
after birth can reduce the number of infant deaths drastically. The care given during the first
28 days of life is known as neonatal care.
RCH Package for Children
:=} Essential Newborn Care
:=} Exclusive breast feeding
:=} Immunization
:=} Appropriate Management of Diarrhoea
:=} Appropriate Management of ARI
:=} Vito A Prophylaxis
:=} Treatment of anaemia
(Details of the above given in Module VI)
Immediately after delivery of the child, the baby should cry and start breathing. After the
umbilical cord is clamped and cut, optimum neonatal care is to be given as follows:
• the air passage (mouth and nostrils) should be cleared.
• the eyes should be cleaned.
• the infant should be examined for birth defects.
• the infant should be cleaned and wrapped in clean linen and placed next to the mother.
• the infant should be put to the breast of the mother as early as possible
but never later than 1-2 hours following birth. (colostrum or first milk, must be
given to the newborn infant).
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Breast Feeding
Breast milk is the complete food for the new born baby. The advantages of breast
feeding are:
• Readily available, sterile and given to the baby directly at body
temperature
• Convenient, requiring no preparation, does not cost money
• Creates a bonding between mother and child
• Ideal formula for the new born and easily digestible
• Protects the child against infections and deficiencies
• Breast feeding may also act as a normal contraceptive method, if the child is not
given any other food in addition
• No danger of allergy
• Can be given even during fever and diarrhoea
• Disadvantages of artificial feeding
• Contamination - Artificial feed and the process of its preparation are prone to
contamination with bacteria.
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• It is expensive.
• The iron from animal milk is not absorbed well.
• Animal milk has less essential fatty acids.
• It may produce allergy.
Breast feeding may sometimes be a problem, and if not treated, may lead to adverse
consequences. The difficulties in breast feeding may be:
=> following caesarean delivery (uncomfortable to the mother)
=> maternal illness (heart disease, eclampsia, diabetes, tuberculosis)
=> inadequate volume of milk
=> breast ailments (engorged breast, cracked nipple)
=> Low Birth Weight
=> Illness (respiratory illness, blocked nose)
=> Over distension of stomach with swallowed air
Serious Complications in Infancy
Sometimes, the life of the infant may be endangered by serious complications
which may be:
• Poor Physical Condition - There may be breathing trouble, the skin may be cold,
tough or pale or bluish in colour.
• Jaundice - Jaundice may develop within the first 2 weeks after birth. This is normal.
However, if it does not resolve soon, the baby looks ill or does not feed properly, it
could be a serious complication.
• Sepsis - If the cord stump is infected, the baby may develop sepsis, which is recognised by
green watery stools, vomiting, lethargy, breathing problems and cold clammy skin .
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Low Birth Weight (LBW)
A normal new born baby weighs between 2.5 Kg to 3.5 Kg. In India, approximately 30-40 per
cent babies are born with birth weight of less than 2.5 Kg. Maternal malnutrition and anaemia
appear to be the most significant causative factors. Short maternal stature, very young age,
high parity, smoking and close birth intervals also attribute to Low Birth Weight (LBW).These
babies require special care and attentionwith regard to feeding ~nd temperature regulation.
Weaning
Weaning is a gradual process starting around the age of 3-4 months, when the mother's milk
alone is not sufficient to sustain the growth and development of the infant. Supplementary
foods have to be added to the infant's diet. Semi-solid foods may be introduced in addition to
breast milk initially.
Immunization
To prevent 6 life threatening diseases like tetanus, poliomyelitis, diphtheria, whooping cough
(pertussis), tuberculosis and measles, vaccines are given to the child, according to the schedule
given below. All the vaccines are given free of charge, at all health centres, by the Government.
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Age
Immediately
after birth
1~ months
2Y.!months
3~ months
9 months
1~24 months
5-6 years
Vaccine &
Dosage
Diseases
covered
Remarks
BeG - 1 dose
Zero Polio - 1 dose
DPT - 1 dose
OPV - 1 dose
DPT -1 dose
OPV -1 dose
DPT -1 dose
OPV -Idose
Measles - 1 dose
DPT booster - 1 dose
OPV booster- 1 dose
DT booster - 1 dose
Tuberculosis
Poliomyelitis
Diphtheria
Whooping cough
Tetanus
Poliomyelitis
by mouth
Diphtheria
Whooping cough
Tetanus
Poliomyelitis
by mouth
Diphtheria
Whooping cough
Tetanus
Poliomyelitis
by mouth
Measles
Diphtheria, Tetanus
Poliomyelitis
Diphtheria,Tetanus
I~ection given
on left shoulder
Oral drops
Injection
Oral drops given
Injection
Oral drops given
Injection
Oral drops given
I~ection
"
oral drops
Injection
.I.(\\.PFI:==:::========:::====~®_-. ================
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Appropriate Management of Diarrhoea
Diarrhoea is a major cause of death amongst infants and children under the age of five years.
Diarrhoea leads to dehydration, caused by loss of fluids from the body due to excessive passage
of watery stools.
• Assessment of dehydration
Checklist
• Patient's
appearance
• Skin elasticity
• Tongue
• Anterior
fontanelle
(soft portion of
the scalp at the
top of the head)
• Urine flow
Mild
dehydration
Severe
dehydration
Thirsty, alert, restless
Pinch retracts
immediately
Moist
Normal
Drowsy, limp, cold anc
sweaty, comatose
Pinch retracts very slowly
(more
than 2 Seconds)
Very dry
Sunken
Normal
Very little or none
The soft spot on her
head is sunken.
When her skin is
pinched, it stays folded
for two seconds.
She has not passed
urine for half a day
~
Her eyes are
sunken
~
She has been
having watery stools
for two days.
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Management of a case of diarrhoea must begin at home. The following measures may be
taken to combat excessive loss of fluids due to diarrhoea:
• fluid intake should be increased.
• breast feeding should be continued.
Medical help should be sought in severe conditions.
ORS should be given to a child suffering from diarrhoea in order to make up for the
lost water and salts.
Oral rehydration salts are available in packets at all Government Health Centres
and chemist shops. In one litre of potable water, the full packet of ORS should
be added. The solution is given to the patient at short intervals. Once made, it
can be used for 24 hours and should be discarded thereafter. A fresh solution
should be made thereafter.
In addition to ORS, fluids available at home like, rice water, dal, buttermilk,
coconut water etc should also be given to the patient.
.:. Take a glass of clean water.
.:. Add a pinch of salt and palm full of sugar.
.:. Mix well and give the solution to the baby suffering from diarrhoea.
One glass
of water
,clo...
One pinch of salt
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Appropriate Management of ARI
Acute respiratory tract infection (ARI) is a major cause of death in infants and children under
the age of five years. Majority of ARIs are self limiting. However, pneumonia is a serious
life threatening illness with high fatality rate .
• Diagnosis of Pneumonia
Pneumonia is diagnosed if the child has cough with:
.:. difficulty in breathing
.:. increased respiratory rate
.:. indrawing of the chest while breathing
.:. inability to breast feed
.:. grunting
.:. excessive drowsiness
If any of the above danger signs is present, the child should be referred to a doctor for
appropriate treatment.
Control of Vitamin A deficiency
Vitamin A is indispensible for normal vision. Deficiency of Vitamin A causes night blindness
and, in extreme cases, total irreversible blindness. Vitamin A is found widely in animal and
plant foods like milk, butter, cheese, eggs, fish, meat, green leafy vegetables and yellow fruits.
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Deficiency of Vitamin A causes the following:
Night blindness (i.e. inability to see clearly in the dark)
!
Dryness of the conjunctiva
!
Formation of Bitot's spots (pearly 'white foamy spots on the conjunctiva)
!
!
Keratomalacia or liquefaction of the cornea leading to complete blindness.
• Treatment of Vitamin A deficiency
Vitamin A deficiency should be treated urgently. All children with corneal ulcers
should be given Vitamin A, whether or not a deficiency is suspected. Vitamin A
deficiency is treated by the administration of 200,000 IV orally on two
successive days.
Administration of Vitamin A to children below 3 years has proved effective in preventing
Vitamin A deficiency. Children between the ages of 9 months to 3 years are to be
given Vitamin A as follows:
==> First dose of 100,000 IV to be given at 9 months of age (with measles vaccine).
==> Second dose of 200,000 IV to be given at 16 months of age with booster of
DPT/OPV.
==> Three more doses of 200,000 IV to be given at 6 monthly intervals.
In addition, children should be given food that is rich in Vitamin A. Episodes
of diarrhoea and worm infestation should. also be promptly treated.
Growth & Development of Infants and Children
"Growth" refers to the increase in the physical size. "Development" refers to the increase in
skill and function. Growth and development are considered together because the child grows
and develops as a whole. It implies not only the physical aspects, but also intellectual, emotional
and social aspects .
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13 Pages 121-130 |
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It is a widely accepted formula that a baby doubles its birth weight at 5 months and triples it at
1 year. Low Birth Weight babies may double their weight earlier, if properly looked after.
RlASllNS FOR lil'ECIAI. CAllE
.,II
•
..I\\J
'1: :::'.:.:,': ::::-:.::<',:':::::~::::~~',: .
;< I
'.
r
• Monitoring of Growth and Development
Regular weight gain is the best indicator of a child's normal health development. If a
child does not put on weight for two successive months, she/he should be referred for
medical advice.
To ensure optimum growth and development, each child should be monitored on a
"Road to Health" growth chart. The main principle behind the monitoring is to measure
periodically the weight for age, de,,-elopment milestones and signals for malnutrition
and infectious diseases, Initially, the birth weight should be noted and thereafter the
baby should be weighed every 3 months. The growth curve should be drawn and
compared with the minimum and maximum weight curves for that age indicated on the
growth chart. It is also handy to enter the date and dose of immunization given to the
child.
o Factors Influencing Growth and Development
The following factors affect the growth and development of infants and children:
=? Genetic inheritance - specially height, weight, mental and social development
and personality
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~ Age - growth rate is maximum during foetal life, the first year of life and then
again at puberty
~ Sex - girls reach adolescence (growth spurt) usually 2-3 years
before boys
~ Physical surroundings and psychological factors
~ Infections and diseases
~ Economic factors
To know whether the infant is developing normally, it is important to know the landmark
milestones in development.
Age of achievement
Major Milestones
1-2 months
3-4 months
4-5 months
6-8 months
12-18 months
18-24 months
Movement of eyes
Turning head towards sound
head control, smile
Rolling over
Sitting, lower incisor teeth erupt
Walking, speaking single words
Speaking simple sentences
Causes of death in Indian children below 5 years
• First 7 days
• First month
• 1 month - 12 months
• 1-5 years
LBW, difficult delivery, respiratory
problems, birth defects, prematurity,
neonatal tetanus.
Same as above and diarrhoea, acute
respiratory infections (ARI) , tetanus.
Malnutrition, ,AR!, measles,
whooping cough, diarrhoea.
Same as above and other diseases.
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Questions
1. Mention 5 danger signs of pregnancy.
2. A pregnant woman, on an average, should gain
.Kg.
3. Mention some of the complications that may arise during deli very.
4. What are the 5 cleans?
5. What are the changes that take place in a woman's body after delivery?
6. Give the immunization schedule.
7. What is growth and what is development?
8. Mention some of the landmark milestones from birth to 2 years of age.
9. How is ORS prepared?
10. Infant Mortality is mostly due to
_
II. Commonest deficiency symptom of Vito A is
_
12. How many doses of Vito A should be given to a child?
Notes:
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13.5 Page 125 |
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POPULATION AND PLANNED PARENTHOOD
"Yield not thy neck
To Fortune's Yoke
But let the dauntless mind
Still ride in triumph over all mischance."
Shakespeare; Henry-IV
SBCT10Il.
1. Population Issues
2. Planned Parenthood
Qr Learning Objectives
~ Teaching Aids
• Flip charts and writing material
• Black board & chalk
0 J.1..•..1T. J..TJ..PFI=========~.
.
t=.
1============
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13.6 Page 126 |
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Reproductive & Child Health Care
Introduction
Population explosion is one of the biggest problems being faced b~ our country while many
countries of the world have already resolved this problem. India is the second most populous
country of the world after China and if growth of population continues at the same pace, it is
likely to stand at number one soon in the coming years. As per the 1991 census, the population
of India was 84.63 crores which accounts for nearly 16 percent of the total population of the
world. In the year 1999, the total population of our country has been estimat~d around 98.13
crores. If we look at the total land area ofIndia, it accounts for only 2.5 percent of the total
land area of the world, Though China has the largest population in the world, the net addition
of population is lower than India. With a natural increase of 1.0 percent, China's population is
increasing by 1.24 crores per year, while in India, the net addition of population is 1.88 crores
every year, which is more than the population of Australia.
India's population which was 23.8 crores at the beginning of this century, increased to 36.1
crores in 1951. In this fifty-year period, the population had doubled, but after 1951, it has more
than doubled in less than 40 years, when the total population was enumerated at 84.6 crores in
1991 census.
1,300,000
;;- 1,100,000
Sc 900,000
~
.~!! 700,000
Q.
~ 500,000
300,000
981,324(1999)
If we look at the history of population growth in the country, a population of 60 crores have
been added to India's population after independence. Wh~le an addition of 10 crores took 42
years prior to 1951, it took less and less time for the addition of every 10 crores after
independence. Of the total increase of 60 crores in the post independence era, the first 10
crores were added in 12.5 years, the second 10 crores in 9.3 years, the third 10 crores in 7.6
years, the fourth 10 crores in 6.4 years and the fifth and sixth 10 crores in 5.8 years.
J.tt\\PFl~~~~~~~~~~~~~~=0~========
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Population And Planned Parenthood
14
12
10
~8
~6
4
2
o
1
234
5
6
TIME TAKEN TO ADD EVERY 100 MILLION TO INDIA'S POPULATION
The rapid growth of population is due to several reasons. Important among them are changes
in the mortality and fertility conditions of the population. The difference between the two is
the main cause of rapid population growth in our country.
Mortality Conditions
The steep decline in mortality conditions has contributed to rapid growth of population. Due
to improvement in medical technology and assistance received from foreign countries, the
health status of the population increased sharply reducing considerably the number of persons
dying per 1000 population. The crude death rate (CDR) was 27.4 in the decade 1941-51.
Which declined to 8.9- in 1997. It means that for every 1000 population, 27 persons were
dying in a year around the independence period, while only 9 persons die per 1000
population at present.
There has also been a reduction in infant mortality rates (IMR) over the years. The IMR refers
to the number of deaths of infants (children below one year of age) per 1000 live births in a
year. At the beginning of this century, the IMR was quite high at 222 in 1911. Out of every
1000 children born in a year, 222 infants were dying before attaining their first birthday. The
IMR, which was 148 in 1951, declined to 71in 1997. Still the level of infant mortality is much
higher in our country as compared to· other nations. The higher level ofIMR has resulted in
perpetuating high level of fertility.
Fertility Conditions
High level of fertility has been the most important component of population growth in India,
which may be measured by Crude Birth Rate (CBR). CBR refers to the number oflive births
per 1000 population in a year. The CBR in 1911 was 49.2 which means that for every 1000
population, 49 births occurred in a year. This declined to 39.9 in 1951, again went up in 1961
and 1971
slow pace
to 41.7 and
of decline
41.1
even
respectively. The fertility
in the post independence
plee•rvioedl .reImt iasinoendly
at a high level with a very
since the eighties that the
pace of decline has somewhat accelerated as compared to the previous periods. In 1981 it was
37.2 which came down to 32.6 in 1991 and was 27.2 in 1997.
=============~==============~0===========================================Module-5
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Reproductive & Child Health Care
Natural Increase of Population
The difference of Crude Birth Rate (CBR) and Crude Death Rate (CDR) determines the natural
growth rate in a population. With a large difference between the two, a large number of persons
is rapidly added to the population and this creates a situation what is known as 'Population
Explosion'. As noted earlier, the crude death rate declined sharply during the last few decades
while the decline in crude birth rate during the same period was not so steep, which resulted in a
large gap between the two. As a consequence, each year increasingly greater number of persons
are added to the population in terms of births and less number of population are removed from
the population in terms of death. This fast addition produced the situation of population explosion.
It is the experience of the population of all countries that transition occurs in mortality and
fertility conditions. This is 'popularly known as 'Demographic Transition'. However, the time
taken for these changes in birth and death rate is very important in terms of population explosion.
Longer time involved in completing the demographic transition produces acute problems of
population explosion due to longer period of high fertility regime.
Inter-state Differentials
In India, all the states are not similar in terms of their performance to reduce population growth.
Though all the states had experienced similar conditions of fertility level in the past, the
transitions achieved have remarkably been difference from state to state. Over several decades,
some states have been able to reduce the growth of population while others are lagging behind.
Generally speaking the states located in the southern part of our country have been able to
control their population growth, while most of the states in the northern part of the country
have a still very high growth of population.
The annual exponential growth rate of the south Indian states during the period 1981-91 has
been lower than that of the states situated in the northern part of the country. For example, the
population of Kemla, Tamil Nadu and Kamataka increased by 1.34, 1.43 and 1.92 percent per
annum respectively. On the other hand, Uttar Pradesh had an annual growth rate of2.27 percent,
Rajasthan 2.50, Haryana 2.42 and Bihar 2.11. The annual exponential growth rate for the
country as a whole was 2.15 percent during this period.
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Population And Planned Parenthood
Use of Contraception
Family Planning
and Unmet Need for
The levels of fertility of a population is directly linked with the extent to which the eligible
couples adopt any method offarnily planning {FP). In ourcourttry, the percentage of couples
using any modem FP method is around 36 percent as per the National Family Health Survey
(NFHS) conducted during 1992-93. The goal is to reach a Couple Protection Rate (CPR) of at
least 60 percent by the year 2001. In India, the major emphasis on adoption of family planning
are on terminal methods which include male and female sterilization. Again, almost all the
users of terminal methods are women. The acceptarice of temporarY or spacing methods are
limited. Out of 36 percent of couples practising family planning in the country, only 5.5 percent
were using any temporary method as per NFHS. There also exists wide variation in the levels
of contraceptive acceptance among different states within the country. It varies from a high
level of 54.4 percent in Kerala to as low as 18.5 percent in Uttar Pradesh.
The term unmet need has been measured. This provides an estimation of demand for family
planning in the country or in a particular state, which could not be provided by the country's
family planning programme.
t:~::;:========:J2I.6
~~46'5
~
17.3
47.3
51.3
54.4
Currently married women who say that they either do not want any more children or that they
want to wait two or more years before having another child, but are not using contraception,
are defined as having an unmet need for family planning. As per this definition, 20 percent
of women in India have an unmet need for family planning. The most populous state, Uttar
Pradesh, has the highest unmet need for family planning (30 percent), followed by Bihar (25.1
percent), Orissa (22.4 percent). Madhya Pradesh (20.5 percent) and Rajasthan (19.8 percent).
All these states are having higher levels of unmet need than the average level ofthe country as
a whole. Southern states like Andhra Pradesh (10.4 percent). Kerala (11.7 percent) and Tamil
Nadu (14.6 percent) have relatively lower levels ofunmet need.
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Reproductive & Child Health Care
Uttar A-adesh
Bitar
Orissa
Madhya A-adesh
Rajasthan
INJIA
Karnataka
Tarril Nadu
Punjab
•••• Kerala
Andhra A'adesh
30.1
25.1
22.4
20.5
9.8
19.5
18.2
14.6
13.0
11.7
. 10.4
Population Policy
Population policy refers to policies formulated by the government in order to achieve population
stabilization by checking the birth rate or growth rate to desired levels through organized public
intervention programmes with the aim of ensurmg higher qualities oflife for the population. In
April 1976 India framed its first "National Population Policy". Modifications were undertaken
to rephrase the importance of the small family norm, offer better services and include newer
contraceptive methods. India was the first country to launch an official family planning
programme way back in ·1952. Since its inception, various approaches have been incorporated
in the family planning programme. Earlier, the 'Cafeteria approach' was tried, which was later
shifted to 'extension' and 'camp' approaches. Recently the focus has been on Reproductive and
Child Health (RCH) approach.
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14.1 Page 131 |
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(iF Learning Objectives
On completion of this module, the participants should be able to:
• Define planned parenthoo<;land explain its merits
• Describe various contraceptive devices and explain their utility and uses
& Teaching Aids
===.==.===~~~':.':.':.~~~-=--=--=-------~--0~:-:-=- ===================Module.5.
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Reproductive & Child Health Care
Introduction
Planned and responsible parenthood entails good health of mother and child, proper development
and attention to children and welfare and caring for each member of the family. Planned
parenthood is directly linked to maternal and infant mortality and morbidity. Only a healthy
girl can grow into a healthy woman who is capable of bearing healthy babies. The purpose of
planned parenthood is to plan the number, frequency and timing of pregnancy which ultimately
affects family size and health.
Reproductive Health implies that people are able to have a satisfying and safe sex life and that
they have the capability to reproduce and the freedom to decide whether, when and how often to
do so. Implicit in this last condition is the right of men and women to be informed of and to have
access to safe, effective, affordable and acceptable methods of family planning of their choice.
Family Planning
Family Planning is defined by the WHO as:
"A way of thinking and living that is adopted voluntarily, upon the basis of knowledge and
attitudes and responsible decisions, by individuals and couples in order to promote the
health and welfare of the family groups and thus contribute effectively to social development
of a country" .
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Populaion and Planned Parenthood
• Need for Family Planning
1. Prevents Unwanted Pregnancies
2. Prevents High Risk Pregnancies
3. Prevents Unsafe Abortions
4. Helps women's body to replenish the lost stores of nutrients
5. Provides Other Health Benefits
eg: (a) Hormonal methods prevent certain cancers
(b) Condom helps in preventing STDs
Earth
!
1
1. FP ensures less demand
on natural resources
2. Better opportunities for
better lives.
1. Prevent LBW
(Low Birth Weight)
2. Ensuresadequate
breast feeding
3. Less differences between
developed & developing
countries ensuring a more
balanced world.
;:.J Nation
1. Helps Nation's
1
I ~en
&.....+ 1. Helpsthem to care
development
2. Faster economic,
educational
improvement
1. Provides family well-being
2. Makes economically viable
3. Is able to provide children
with enough food clothing,
housing & education
for their families
2. Helps men to
provide a better
life for their families
Pregnancy should be avoided:
• Too early (before 20 years of age)
• Too late (More than 35 years of age)
• Too many (More than 2 children)
• Too close (Less than 3years gap)
=============:t0Jl:i ==========Module-5
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Reproductive & Chtld Health Care
• Contraceptives
In simple words, contraceptives are family planning methods that prevent
unwanted pregnancies.
Client based approach to Family Planning under the
RCH Programme
The client based approach under the RCH programme entails that correct and complete
information must be given to a client before letting her adopt a family planning method. This
information should include:
..t.\\•P F 1 :::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::~®l=::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::::=
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Contraceptive choices available to the client i.e.
eligible couple
I
Temporary (Reversible)
Method
Contraceptive Methods
I
1
Premanent(Irrevesible)
Method
Temporary Methods
I
I I Natural
1
I I Barrier
1
Male
Condom
1
I I Chemical
~
Intra-Uterine
Contraceptive
Device
Today
!
Cut-T
Abstinence Withdrawal
Rhythm Method
Lactational Amenorrhea Method
I1
Non-
Hormonal
I Hormonal
1
Saheli
Oral
!
Mala-D
Mala-N
Injectable
!
Depat-
Provexa
!
Male Sterilization
(Vasectomy)
1
Female Sterilization
(Tubectomy)
============~®J:==================~ModUJe-5
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14.6 Page 136 |
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Temporary Methods of Contraceptton
I. Natural Methods
+ Mechanism of Action
This implies that the couple should abstain from intercourse completely so that
there is no chance of fertilization.
2. Withdrawal method (or Coitus interruptus)
+ Mechanism of Action
In this method, the man withdraws his penis from the vagina of the woman just
before ejaculation, i.e. he ejaculates outside the woman.
3. Rhythm method (or Fertility Awareness Based Method)
+ Mechanism of Action
The couple should abstain or avoid having sexual intercourse during ovulation.
Ovulation usually takes place during the middle of the menstruation cycle and 14
days before the onset of the next menstrual bleeding. The ovum survives for about
24 hours and the sperm can remain alive in the female tract for 72 hours. There is,
therefore, about 8-10 days in the midcycle when theoretically fertilization can occur
after unprotected intercourse. The remaining days, i.e. around 8-9 days immediately
after the onset of the menstrual bleeding and 8-9 days before the start of the next
menstrual bleeding constitutes the "safe period", as unprotected intercourse will
not result in a pregnancy. This calculation is done based on an average 28 day
menstrual cycle .
.•tt.\\'PFI=============-=-"=:@l====================
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-+ Advantages of Natural Methods (Abstinence+Coitus Interr"ptus+Rhythm method)
.:. Can be used to avoid pregnancy
-+ Disadvantages
.:. High failure rates
.:. Ovulatory mucus is difficult to discern in the presence of vaginal infections
(mucus becomes thin and watery during ovulation)
-+ Health Benefits
No health benefits
-+ Health Risk
No health risks.
Use of Natural Family Planning may cause problems in a couple's relationship.
Some couples dislike the prolonged periods of abstinence. Others may find
withdrawal during intercourse difficult.
~============~@~~~==~====MOdUk-5
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Myth
Reality
Myth
Reality
Natural Family Planning Methods - Myths & Realities
: Only highly educated couples can use naturalfamily planning methods.
: Studies have shown that couples worldwide, both educated and
uneducated, can use fertility awareness based methods successfully if
they are properly trained and highly motivated.
: Most men will not accept abstinence during the fertile period.
: While this may be true in some circumstances, studies have shown that
for most couples who choose to practise Natural Family Planning (NFP)
methods, the man reports that he is not particularly disturbed by the
required abstinence.
The Lactational Amenorrhoea Method (LAM) is the use of breast feeding as a temporary
family planning method. ("Lactational" means related to breastfeeding. "Amenorrhoea"
means not having menstrual bleeding).
-+ Mechanism of Action
.:. LAM acts by suppressing ovulation(release of eggs from the ovaries), because
breastfeeding at regular intervals changes the rate of release of hormones
.:. Effectively prevents pregnancy for at least 4 months, if women continue breast
feeding at regular intervals during day and night.
.:. Most effective during the immediate months following child birth. Effectiveness
after 4 months is not certain
.+•.t\\PFl=========:l@~=========
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.:. Dependent upon maternal behaviour. Frequent breast feeding may be inconvenient,
especially for working mothers
• who is less than 6 months postpartum. and
• who is exclusively breast feeding.
Exclusive breastjeeding is characterized by:
• breast feeding whenever baby desires
• continuing night time feedings and
• not substituting other food or liquids for breast milk meal.
-+ Health Benefits
• For Mothers
.:. Reduces postpartum bleeding
.:. Reduces chances of developing breast cancer later in life
.:. Best source of nutrition. Also protects from life-threatening diarrhoea
.:. Helps to develop a close relationship between mother and baby
(psychological benefit)
If the mother has HIV (virus causing AIDS), there is a small chance that the virus
will pass through the milk to the child.
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Reproductive & Child Health Care
.:. diabetes
.:. iron deficiency anaemia
.:. malaria
.:. sickle cell disease
.:. gall bladder disease
.:. thyroid disease
.:. uterine fibroids
The only conditions that limit the use of LAM are conditions that make breast feeding difficult
or that rule out breast feeding. A woman should not breast feed if she is taking certain drugs
(e.g. reserpine, cortisone, radio active drugs, lithium, anticoagulants). Viral hepatitis can also
be transmitted through breast feeding.
As mentioned earlier, HIV /AIDS can be passed on to the baby through breast milk.. However,
since the benefits outweigh the risks, the mother may continue breast feeding, unless she can
afford other foods for the baby. In such cases, the woman may choose an alternative
contraceptive .
..tt\\.PFI========S@J::=========~
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15.1 Page 141 |
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Myth
Reality
LAM : Myths and Realities
Feeding only breast milk to an infant is harmful.
"Exclusive" breastfeeding is not harmful to the infant. Infact, breast milk
is the ideal nutrition for infants during the first six months after birth.
Women who are HIV positive or at risk for HIV, should not breast feed
their babies and cannot practise LAM.
If the mother has HIV, there is a chance that her breast milk will pass the
virus to the baby. For these women, dangers of passing HIV to their infants
must be evaluated against the benefits ofbreast feeding. If an infant can be
guaranteed access to safe, nutritionally adequate substitutes for breast
milk, that may be the best choice for HIV positive mothers to feed their
infants. However, if these conditions cannot be met and in areas where
infectious diseases and malnutrition cause many infant deaths, breast
feeding may still be the best choice for HIV positive women and their
children. Women who are HIV positive should be counselled about all
risks and benefits of breast feeding.
II. Barrier Contraceptives
-+ Mechanism of Action
Condoms act by:
.:. creating a barrier that prevents sperms from gaining access to the female
reproductive tract
.:. killing or immobilizing sperms if treated with spermicide for added protection
against possible breakage or leakage
-+ Condoms are appropriate for:
.:. men who desire to actively participate in family planning
.:. couples needing a temporary method while waiting for a long term method
(IUCD/injectables/sterilization) or want a back-up method
.:. those who need a method immediately
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Reproductive & Child Health Care
I
.:. breast feeding mothers who need contraception .
•:. couples who have infrequent intercourse .
. ~ Advantages
.:. Very effective if used correctly during every act of sexual intercourse
.:. Easily available
.:. Give protection against STDIHIV /AIDS, when used correctly, during every act
of sexual intercourse
.:. Can be used immediately after childbirth
.:. Can be used as a back up method
.:. Allows the man to share the responsibility for Family Planning
.:. Can be stopped at any time
.:. Easy to keep on hand in case sex occurs unexpectedly
.:. Can be used by men of any age
.:. Increased sexual enjoyment because no need to worry about pregnancy
or STDs
Condoms work well when used correctly with EVERY
act of sexual intercourse.
NEVER REUSE A CONDOM
~ Disadvantages
.:. May cause itching in people who are allergic to latex
.:. High user failure rate
.:. May decrease sensation, making sex less enjoyable
.t•t.\\.PFJ~~~~~~~~~~~~=@::=~~~~~~==~~~~==~~=
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.:. Requires use during each episode of intercourse. 'Couple must allow time to
put the condom on the erect penis before sex
.:. Requires supplies to be handy when intercourse occurs
.:. Resupply must be available
.:. Sometimes, if stored too long or in too much heat, sunlight or humidity, or if
used with oil based lubricants, condoms may break during use
.:. A man's cooperation is needed for a woman to protect herself from pregnancy
and disease
.:. Poor reputation. Many people connect condoms with immoral sex, sex outside
marriage or sex with prostitutes
.:. May embarrass some people to buy, ask partner to use, put on, take off or throw
away condoms
~ Health Benefit
Condoms are the only contraceptive method to provide protection against STDs
including HIV IAIDS.
Management of Side-Effects
Problem
Assessment
Management
• Condom broken or
breakage suspected
• Check Condom for a
hole or demonstrable
leak
• Discard and use new condom
Ifleakage suspected, consider
"Morning After Pill"
• Local irritation to
the penis
• Determine whether
allergic (some may be
allergic to latex rubber).
Rule out infection
• If allergic reaction occurs,
ensure that the condom
is not medicated
• Diminishes sexual
pleasure
• Couple complaining of
decreased sexual pleasure
or decreased sensation
during intercourse
• If not tolerable,
consider another method.
~~'=-'=-'=-~~~~~~"':.."':..-__~--__-~-_-_-_-_-"_@-_::-:====================MOdule-S
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DO NOT use mineral oil, cooking oil, petroleum jelly, skin cream as lubricants for
a Condom
Just one unprotected act of se~ual intercourse can lead to pregnancy or STDs.
Condom EVERY TIME is important
+ Non-Contraceptive Benefits
.:. Latex Condoms prevent the spread of STDs (including HIV)
.:. Lubricated Condoms facilitate intercourse if the vagina is dry
.:. Condoms may help to decrease premature ejaculation in men
.:. Help prevent ectopic pregnancies in women as well as pel vie
inflammatory diseases
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.~ ,,:.r!?
@t. I
.
!
Only put the condom on when the penis is hard and erect.
The fluid that is often released during the early stages of an
erection can contain sperm (and STD organisms). So put
the condom on before there is any contact between the penis
and the vaginal area.
Tear along one side of the foil making sure that you don't
rip the condom inside. Squeeze the opposite side of the foil
and remove the condom carefully. Condom are strong but
they can be tom by sharp finger nails or jewellery. Avoid
using scissors or blades, too.
Excess air trapped inside a condom could cause it to break,
so expel most of the air from the closed end as you put the
condom on. Squeezing the closed end between your thumb
and forefinger, place the condom over the erect penis
making sure that the roll is on the outside.
Using your other hand unroll the condom gently down the
fully length of the penis as far as it will go, still squeezing
the closed end. Make sure the condom stays in place during
sex; if it rolls up, roll it back into place immediately. If the
condom comes of completely then a new condom must be
used before sex continues.
Withdraw the penis soon after ejaculation holding the
condom firmly in place at the base of the penis.
Wait until the penis is completely withdrawn before
removing the condom, Remember to keep both the penis
and the condom clear from contact with your partner's body.
Wrap the condom in a tissue and dispose of hygienically
(not down the toilet).
==============t@I--_-_-_-_-_-_-:...-_-_-:...-:...-_-:...-:...-:...-:...-:...-:::.-=Module-5
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Reproductive &: Child Hel!lthCare
Myth
Reality
The condom comes off or breaks during sexual intercourse and permanently
lodges inside the woman 's body.
Condoms do occassionally break. The male condom can slip off inside
the woman's vagina but she can remove it. Proper storage and avoidance
of oil-based lubricants prevent the deterioration of condoms, a major cause
of breaking.
Male Condoms will weaken a man's strength, which may result in
impotence. (unable to have an erection)
Afew men may have trouble keeping an erection while using male condoms,
but condoms themselves do not cause impotence. Many men in fact find
that condoms help them keep an erection longer and reduce premature
ejaculation.
Condoms are only used with prostitutes.
Condoms are regularly and safely used by millions of couples to prevent
pregnancy. Married couples all over the world use condoms.
III. Chemical Contraceptive
Chemical contraceptives are spermicides that are placed in a woman's vagina before sexual
intercourse.
The only vaginal chemical contraceptive available in India is 'Today'. Today is a specially
shaped, soft pessary which is inserted deep in the vagina, at least 10 minutes or upto one hour
before intercourse.
-+ Mechanism of Action
After being placed in the vagina, the pessary melts and releases an effective
spermicidal which destroys sperms on contact and thus prevents conception .
•:. Safe, almost every woman can use
.:. Effective, if used correctly every time a woman has sexual intercourse
.:. It can be started any time during the monthly cycle, and soon after child birth,
abortion or miscarriage
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Populaionand Planned Parenthood
.:. It is non-hormonal, there is no possibility of any side-effect
.:. No effect on breast milk
.:. Can be stopped at any time
.:. Helps prevent some STDs
.:. May increase vaginal lubrication
.:. Can be inserted as much as one hour before sex to avoid interrupting sex
.:. No need to see a health care provider before use
.:. Has to be inserted before intercourse. May interrupt sex if not inserted
beforehand
.:. May cause irritation, especially if used several times a day
.:. Has to be kept away from excessive heat. Exposure to sunlight or excessive
heat, may cause it to melt
+ How to use a vaginal pessary
Taking one pessary between the finger tips, it is inserted deep into the vagina as far
as the finger goes. 10 minutes are allowed for the contraceptive action to take
effect. Vaginal contraceptives remain effective for about an hour after insertion.
Spermicides can kill organisms that cause some STDs. The best protection during
sex may be using both a condom and spermicide together, every time. If only one
method is used, the condom is best. But, when a woman cannot convince her partner
to use condoms, a woman·controlled vaginal method (spermicides) might be used to
provide some degree of protection .
•:. Keep away from excessive heat
.:. Men are advised to wait for a few minutes after intercourse to let the penis
return to normal size before urinating
.:. Women are advised not to wash immediately but to allow it to pass out routinely
~~~~~~~===~~~~~~~~.~.==~=-=_==-=_==-=_=-=_==-=_==-=_=~=M-o:du_le@-5 _
<
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Reproductive & Child Health ~
,.,2 h'.J
9 .~~.¥
~..#£ "~Q
.£
with urine. This would ensure that the pessary remains inside as long as sperm
remains inside
Myth
Reality
Myth
Reality
Chemical Contraceptives: Myths & Realities
Spermicides cause birth defects
No, they do not cause birth defects. Spermicides do not harm a baby even
if a woman uses them while pregnant.
Spermicides cause cancer
No, in fact, they may prevent cancer of the cervix.
IV. Intra Uterine Contraceptive Device (IUCD)
An intrauterine contraceptive device (IUCD) is usually a small flexible plastic device, coated
with copper that is inserted· into the uterus under medical supervision. Almost all brands of
IUCD have one or tWo strings tied to them. The string hang through the opening of the cervix
into the vagina. The user can check that the IUCD is still in place by touching the strings. An
IUCD is removed by pulling gently on the strings.
+ Mechanism of Action
The device changes the uterine lining, thereby preventing implantation of the fertilised
egg. It also decreases sperm mobility, thereby preventing fertilization in the
fallopian tube.
+ Advantages
.:. Provides long term contraception (3-5 years)
.:. Very effective (failure rate is 1-3%)
.:. Does not interfere with intercourse
.+•.t\\PFI~===~~~==@==.~===~====:
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.:. Increased sexual enjoyment because no need to worry about pregnancy
.:. Does not have to be used daily
.:. No hormonal side effects
.•:. Offers privacy to the user
.:. Can be inserted immediately after child birth or abortion
.:. Can be used till after menopause
.:. Immediate return to fertility upon removal
.:. No interactions with any medicines
.:. Does not affect breast feeding
(. No extra supplies required by client
• Menstrual changes - common in the first 3 months, but likely to normalise
afterwards
• Heavy and painful periods during the first few months in many users, possibly
contributing to anaemia
• Increased risk of pelvic infection
These side effects can be avoided by treating existing RTIs and providing
counselling on maintaining genital hygiene.
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Reproductive 4 c;hiltl Health Care
.:. Does not provide protection against STDsIHIV. Not a good method if either
participant has multiple sex partners
.:. Pelvic inflammatory disease (PID) is more likely to follow if a woman with STD
uses an IDCD. PID can lead to infertility
.:. Client cannot start or discontinue on her own. Medical/paramedical supervision is
required for insertion and removal
.:. Need to check the string after every menstrual period.
The IDCD is not the best method for a woman who has not had a baby and wants a
baby in future. Reproductive Tract Infection (RTIs) including STDs are more
common in women using IDCDs. RTIs can lead to PID, which in turn can lead to
infertility. Also, a woman who has not had children is more likely to expel the
IDCD because her uterus is small.
'
"_"'_"~:N' C";Iotre"
. "I)fJtJ
wllliti I
I ,"1'1.111
\\
\\. eeL"•'. I
J
IiI
I
\\"a=t_a I
I
-+ Health Benefit
Does not affect breast feeding
-+ IUCDs are most appropriate for a client who
.:. is at medical risk for pills
.:. wants a long-term, effective, easily reversible method
.:. is in a monogamous relationship
.t•t.\\.PFI=======~@~=========
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16.1 Page 151 |
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.:. the 1st and 7th day of the menstrual cycle .
•:. immediately after delivery OR 6 weeks after delivery .
•:. immediately after abortion.
~ Women with these conditions CAN use IUCDs
.:. Benign breast disease
..: Diabetes
.:. Breast cancer
..: Liver disease
.:. Headaches
..: Malaria
.:. High blood pressure
..: Thyroid disease
.:. Blood clotting problems
..: Epilepsy
.:. Varicose veins
..: Nonpelvic tuberculosis .
.:. Heart disease
..: Past ectopic pregnancy
.:. History of stroke
..: Past peivic surgery
Myth
Reality
Myth
Reality
IUCDs : Myths & Realities
The/UCD might travel through a woman's body, may be to her heart or
her brain.
The IUCD usually stays in the uterus till it is removed. /fit does come out,
it comes out through the vagina. In the rare event that the IUCD perforates
the uterus, it will remain in the abdomen. The diaphragm prevents the
IUCD from travelling to the chest.
IUCD prevents pregnancy by causing abortion.
IUCD prevent pregnancy by delaying sperm transport. It does not destroy
the egg.
IUCDs cause cancer.
IUCDs do not cause cancer.
========================:::======@=====================:=MOdUIe·S
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Reproductive & ChildHt!althC~
v. Non-Hormonal Contraceptive
+ Mechanism of Action
Centchroman or Saheli acts by-
.:. Hastening tubal transport of embryo
.:. Changing the uterine lining and bio-chemical markers of implantation .
•:. Inhibiting implantation in uterus .
•:. Easy to use - Once a week pill only
.:. Convenient to use
.:. Safe, no side effects
.:. Economical
.:. The effect of the drug is easily reversible
.:. Free from deleterious effects on the baby, if accidentally
early pregnancy.
ingested in
+ Disadvantage
.:. Prolongs menstrual cycle
+ Dosage and Instructions for Use
Centchroman (SAHELI) is supplied in 30 mg tablets. The first tablet should be
taken orally on the FIRST DA Y of the menstrual period and thereafter twice-a-
week, 3 and 4 days apart on the same days every week for 3 months, followed by
once-a-week, (same day every week) for as long as protection is desired. In case a
tablet is missed, it should be taken as soon as possible and the normal schedule
continued. As an additional precaution, condoms may be used till the next period.
If a tablet is missed for more than 7 days, it should be re-initiated like a new user,
i.e. bi-weekly for the first 3 months and weekly thereafter .
•:. Occasionally, the menstrual cycle is prolonged in some users but delayed
menstruation is of no consequence if tablets have not been missed. However,
if the delay exceeds 15 days, a doctor may be consulted to rule out pregnancy .
•:.. In case delay is due to pregnancy, SAHELI pill should be discontinued immediately.
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Populaion and Planned Parenthood
f ..
Side Effects
1. Minor & Common
a. Headache
b. Nausea
c. Sore breast
d. Weight gain
e. Spotting
f. Dizziness
g. Delayed menses
2. Rare & Serious
a. Hypertension
b. Thrombo-embolic
c. Coronary/Cerebral
d. Cancer - Breast
episodes
Infarctions
e. Cancer - Cervix
Centchroman
Steroidal
combined
pills
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
No
Yes
8% of cycles
+
No
Yes
No
Yes
No
Yes
No
(Beneficial)
(?)
No
(?)
SAHELI oral pill should not be taken by women suffering from the
following disorders:
.:. Recent history of jaundice or liver disease
.:. Polycystic ovarian disease .
•:. Chronic cervicitis or cervical hyperplasia
.:. Severe allergic conditions
.:. Chronic illness like tuberculosis, renal disease
-:. Nursing mothers in the first 6 months.
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Reprotiuctive & Child Health Care
VI. Hormonal Contraceptives
Hormonal contraceptives are those that have either a combination of oestrogen and progesterone
or only progesterone.
Types of Hormonal Contraceptives
(A) Oral
(B) Injectable
• Oral Contraceptive Pills (OCPs)
These contain both Oestrogen and Progesterone and are called "combined oral
contraceptive pills". The oral pills are available under the brand names of Mala-D,
Mala-N, Ecroz, Pearl, etc.
-+ Mechanism of Action
Combined oral contraceptive pills act by:
(. thickening the cervical mucus at the mouth of the uterus (cervix) preventing
sperm entry.
\\
] \\,
Supp' •• ' O"",1J.tia.
"
C"'V'1r cUutI., •.
I
Ilndonu:crblltftiftl
MECHANISM OF ACTION
The pills are available in packs of21 and 28 tablets. The pills are started anyday from the first
to the 5th day of the menstrual cycle, counting the first day of bleeding as day one. One pill is
taken every day. In the 28 pill pack, the next pill cycle should be started as soon as all the pills
in the first pack are over. The pills should be taken every day without fail. In the 21 pill pack,
the new packet should be started seven days after the previous one is over. If the user misses
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Populaion and Planned Parenthood
one tablet, she should take it as soon as she remembers. If she misses 2 tablets, 2 pills should
be taken together, and then one pill a day as usual. She should also use an additional
contraceptive method for that cycle.
0000000
0000000
0••0•0•0•0•0•0
-+ OCPs are appropriate for
.:. Women of any reproductive age or parity, who want highly effective protection
against pregnancy
.:. Breast feeding mothers six months postpartum
.:. Women with history of anaemia
.:. Women with severe menstrual cramping
.:. Women with irregular menstrual cycles
.:. Women with history of ectopic pregnancy
-+ Advantages
.:. Safe and 100 per cent effective if taken regularly
.:. Regularises the menstrual cycle and controls heavy flow. It also reduces
menstrual cramps
.:. Can be used at any age, from adolescence to menopause
.:. Can be used by women who have had children and those who have not
.:. User can stop taking pills at any time
.:. Fertility returns soon after stopping
.:. Can be used as an emergency contraceptive
.:. Can prevent or decrease iron deficiency anaemia
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.:. Prevents ectopic pregnancies
.:. Can be started immediately after an abortion or miscarriage
.:. Can be used as long as required, no rest period required
.:. Does not interfere with sexual intercourse
.:. Increased sexual enjoyment because there is no need to worry about pregnancy
Side effects like nausea, sore breasts or dizziness can occur in the first 2-3 cycles. The woman
should be reassured that these symptoms are normal and would disappear after a few months.
-+ Disadvantages
.:. User dependant. It is not highly effective unless taken every day
.:. Effectiveness may be lowered when certain drugs for epilepsy and tuberculosis
(Rifampicin) are taken
.:. Continuous supply may sometimes be a problem. A new packet of pills must be at
hand every 28 days
•
•:. Does not protect against RTIs/STDsl AIDS
.:. Oral pills (containing Oestrogen) should not be given to lactating mothers, as it
reduces the quantity of breast milk
.:. Nausea/dizziness in the first 3 months of usage
Women should not be given OCPs in the following conditions:
.:. Jaundice I Liver dise.ase within the last one year
.:. Smoker over 35 years of age
.&•••• PFI=============®~,?=. =========
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Populaion and Planned Parenthood
... ... -.
.,-
..C.o.- ~ •.•••.•
~•• .,.+.
.•
[!] Day
Menstruation
begins
Day [1J
Day [I]
Day [I]
IT] Start taking
Day
pill
r-
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16.8 Page 158 |
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Reproductive & f;hild./Jealth .c;~
Myth:
Reality:
Myth:
Reality:
Myth:
Reality:
Myth:
Reality:
Myth:
Reality:
Myth:
Reality:
The pill is a strong, dangerous drug and using it can permanently harm a
woman.
Oral contraceptives have now been extensively tested and evaluated and
have been found to be safe and effective for most women.
Use of the pill will CaUseinfertility.
There is no evidence that oral contraceptive use decreases future fertility.
The pill causes cancer.
There is no conclusive evidence showing that pills cause cervical or breast
cancer. Research has, in fact, shown that oral contraceptives offer
protection against ovarian and endometrial cancers.
A woman should stop using the pill after a year or two to give her body a
'rest' from the hormones.
There is no evidence that women taking pills should stop taking them
periodically to 'rest' their bodies. Infact, the increased risk of pregnancy
that occurs when a woman stops taking pills is much more of a health risk
than continuing to take them.
Pills cause weight gain.
The maximum weight gained is half a kilo in one year, if at all.
Women over 35 should not take the pill
Pills cause osteoporosis and menopause symptoms. Only heavy smokers
over 35 are discouraged from using the pill because of the high
cardiovascular risks they face.
Pills cause hormonal imbalance
Menstrual cycle becomes regular and lighter, with fewer cramps.
Pills may cause foetal deformity
Even if the pills are accidentally used during undiagnosed pregnancy, the
foetus is not at risk.
• Hormonal Injectables
These are injections containing the hormone progesterone only. They are given
intramuscularly, once every 3 months. They are available in India as DMPA (depot
medroxy-progesterone acetate). The failure rate is very low .
.•.•PFI========::I®1=======~===
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Populaion and Planned Parenthood
!
-+ Mechanism of Action
Injectable hormonal contraceptives act by:
.:. Suppressing ovulation
.:. Thickening the cervical mucus, preventing entry of sperms
.:. Private. No one else can tell that a woman is using it
.:. Rapidly effective (within 24 hours of taking the injection)
.:. Provides long-term pregnancy prevention
.:. No daily pill taking
.:. Can be used at any age, even older women (over 35)
.:. Convenient - only 4 planned doses in a year
.:. No oestrogen related side effects
.:. No androgenic side effects
.:. Helps prevent ectopic pregnancies
.:. Helps prevent endometrial cancer
.:. May help prevent ovarian cancer
.:. Does not affect breast feeding - neither in quantity or quality
=============:::l@C=========:Moduk ..s
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Reproductive & Child H~altltCare
I i
ii
- if",
i.i·
•
•:. Decreased menstrual blood flow, thereby preventing or decreasing iron
deficiency anaemia
.:. Prevents ectopic pregnancy
.:. Possible decrease in PID (Pelvic Inflammatory Disease)
.:. May make seizures less frequent in women with epilepsy
.:. Indirectly lessens the chances ofRTIs, because due to amenorrhoea, women would
not use dirty cloth during menstruation.
-+ Disadvantages
.:. Causes menstrual changes
.:. irregular bleeding/spotting
.:. amenorrhoea (40-60%)
.:. May cause headaches, breast tenderness, moodiness, nausea and acne in
some women
.:. Undiagnosed vaginal bleeding
.:. Breast lumps/breast cancer
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• Breast feeding
• After abortion or miscarriage
Any time it is reasonably certain that she
is not pregnant
Any time during the first 7 days after the
onset of menstrual bleeding
6 weeks after child birth
Immediately
OR
within the first 7 days after abortion or
miscarriage
.• Dosage
One dose (150 mg) of OMPA is given once every 3 months.
The injection is given intramuscularly.
INJECfION SITE.
DO NOT MASSAGE THE
VII. Emergency Contraception
After unprotected sex, emergency oral contraception can prevent pregnancy. This type of
contraception is also called "postcoital" or "morning after".
.• Mechanism of action
It acts mainly by stopping ovulation (release of egg from the ovary), and also by
preyenting implantation, if fertilization has already occured.
Emergency contraceptives can be given torape victims and also in case of missed oral
pills or tearing/breaking of a condom.
If the client has had unprotected intercourse in the past 72 hours (Le. 3 days), pregnancy
can be prevented by taking the "post coital" or "Morning After Pill". This consists
of a combination of oestrogen and progesterone. Two tablets should be taken
immediately (i.e. within 72 hours) and another two tablets after 12 hours.
==============s®t:=====~===~.MOdUle-S
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Reproductive &- ChildHettlthC~
The pill works by interfering with tubal motility and rendering the endometrium unsuitable for
implantation.
-+ Advantages
If taken within 72 hours of unprotected intercourse, it is 98% effective. However, the
longer the time from intercourse to therapy, the less effective it is in preventing
pregnancy.
Because of the short treatment, even women of age 35 or older, who are heavy smokers,
can take emergency oral contraceptives.
-+ Disadvantages
.:. Nausea (temporary) and/or vomiting
.:. Spotting/irregular bleeding/menstrual bleeding within 7-10 days of medication.
The Morning After Pill should not be used as a routine method of contraception. It
may be used in the following unusual or emergency conditions -
• Unprotected intercourse
• An IUCD has come out of place
• After rape.
Emergency Oral Contraception should NOT be used in place of family planning
methods. It should be used ONLY IN AN EMERGENCY
In addition to emergency oral contraception, an IUCD, inserted within 24 hours of unprotected
intercourse, can also prevent pregnancy, by preventing implantation of the fertilized ovum.
Myth:
Reality:
Myth:
Reality:
Emergency contraceptive is an abortion.
Emergency contraceptive pills work within thefirst 3 days after unprotected
sexual intercourse. Pregnancy, which most people consider to be the
implantation of a fertilized egg, does not begin until about five days after
fertilisation.
If emergency contraceptionfails, I will have a damaged baby.
There is no evidence that emergency contraceptive pills cause birth defects
in the event that they fail .
.+•.t\\PFl~=~========~=~®-"'----------------------------_-:--
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PERMANENT METHODS OF CONTRACEPTION
(STERILIZATION)
Sterilization is a permanent surgical method of preventing pregnancy. It is a quick, easy and
safe procedure that may be adopted by both men and women. Sterilization in women is called
Tubectomy and that in men is called Vasectomy.
The guidelines of performing sterilization, as laid down by the Government of India are:
• Age of husband not less than 25 years
• Wife should be more than 20 years but less than 45 years of age.
• Couple should have atleast two living children
• Decision for the operation should be voluntary.
I. Vasectomy
Vasectomy is the surgical means of permanently terminating fertility in men. Vasectomy is
performed under local anaesthesia and consists of clamping the vas deferens (tubes that transport
the sperms from the testes).
Vasectomy produces azoospermia, i.e. the ejaculate is devoid of sperms. There are
two types of vasectomy:
A. Scalpel Vasectomy
This is the standard method in which a scalpel (surgical blade) is used to make a small
incision of 1 cm in the man's scrotum. The two vas deferens are identified, gently
lifted out by forceps through the incision and blocked by cutting a small piece of vas
and tying the cut ends. The vas are then returned to the scrotum and the incision is
closed with 1-2 sutures (stitches).
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c.e Reprod'IU:live & ChUdHeet.ltlt.
j
In this method, incisions or sutures are not needed, as a small puncture hole is made in
the scrotum with a sharp tipped forceps. The opening i&stretched to locate the vas
which are pulled out and blocked by the same method used in the standard approach.
No sutures are required to close the puncture .
•:. minor swelling of the scrotum
. (. bleeding or collection of blood (haematoma) in the scrotum
0+ Warning Signs
The warning signs that require immediate medical attention after vasectomy are -
(. bleeding or pus at the site of operation
.:. inflammation at the site of operation
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Poprtlaion and Planned Parenthood
•• Vasectomy is appropriate for
.:. Couples certain they need no more children
.:. Couples where age or health problems of wife might cause high-risk pregnancy
•• Advantages
.:. Very effective
.:. Simple surgery done under local anaesthesia
.:. Less surgical risk than with female sterilization
(. No further worry about contraception
.:. No long term side effects
.:. Not immediately effective (requires upto 20 ejaculations to make the ejaculate free
of sperms)
.:. Uncommon complications of surgery
.:. No protection against STDs
.•:. Reversal of surgery is difficult and expensive
Vasectomy is NOT castration. It does NOT affect the testes
and does NOT affect sexual ability
Vasectomy does not ensure azoospermia (absence of sperms in the ejaculate)
immediately after the operation. It usually takes about 20 ejaculations or 3 months
for the ejaculate to be free of sperms. Condoms or any other Family Planning
method must be used during this period to prevent pregnancy. Ideally, the man
should undergo two semen tests three months after the operation, to be sure that there
are no sperms in the ejaculate.
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Reproductive & Child Health Cue
II. Tubectomy or Tubal Ligation
Tubectomy is a surgical procedure where the fallopian tubes are cut and tied to prevent the ova
(eggs) from meeting the sperms. It may be performed at any time after delivery (post partum),
with an MTP or as an interval procedure.
.• Mechanism of Action
Blocking the fallopian tube prevents conception by preventing sperms from reaching
the ovum. There are two methods of tubectomy:
A Minilaparotomy or Minilap
A small cut (about 1") is made in the abdomen. The fallopian tubes are identified
through this incision, pulled out, tied and cut. The skin incision is then sutured by 2-3
stitches.
B. Laparoscopy
An instrument called laparoscope is introduced into the abdomen through a very small
cut. The surgeon gets a direct view of the tubes through this instrument. The tubes are
blocked without putting the surgeon's hands into the abdomen.
·0 o
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Tubectomy is appropriatefor
.:. Couples certain they want no more children
.•:. Women whose age or health problems might cause high-risk pregnancy.
Adl1antagesof Tubectomy
.:. Very effective
.:. Simple surgery performed under local anaesthesia
.:. No change in hormonal functions
.:. No long term side effects or health risks
Disadl1antIJges
.:. Does not protect against RTIslSTDslHIV/AIDS
.:. Infection or bleeding at the operation site
.:. Injury to internal organs
.:. The formation opf sperms and ova continue even after sterilization operation. The
sperms and ova die a natural death in their restricted passage and do not cause any
harm to the body
============================®~==========Module-5
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Reproductive & ClUld Health Ct.In!
Contraceptive Methods at a Glance
Temporary Methods
• For Men
SI. Type
No.
Mode of Use
Benefits Side .E. ffects
1. Condoms
(Nirodh)
To be worn over an erect
penis
during
sexual
intercourse. Each Condom
should be used only once
Easy to use
•• Can
prevent
sexually
tran
smitted diseases
(STDs) including
AIDS
• No side
effects
• Some men
complain
that
condoms
interrupt sex
or embarass
them
• For Women
2. The Pill
Pill taken daily orally for
28 days (or 21 days with a
gap of 7 days)
• Easy to use.
• Nursing
• Safe method.
mothers and
.Very useful for newl those on Anti
married women,
TB Drugs
who would like to
should not use
delay their first
pregnancy
this.
• Chances of
bleeding,
weight gain,
mild headache
etc.
• Not advised for
women above
35 years, with
liver problem
and those who
had painful
swelling of leg
in previous
pregnancy
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3. Intrauterine
Contraceptive
Device (IDCD)
A 'T' shaped devise that
a specially trained
person places inside the
womb
• Effective
• Reversible
• Long
term
method (IDCD
lasts for atleast
3 years) 0
• Menstrual
period may
be heavier
and longer in
the
beginning.
• Increased
risk of RTIs/
STDs for
women if
asepsis is not
maintained.
• Woman
have to check
for the tail of
IDCD
regularly.
• For Men
Male
Sterili1ization
(Vasectomy)
A permanent contraceptive
method for men who are
sure that they will not want
any more children
Safe
•• Simple
convenient
surgery done
in a few
minutes in a
health centre.
• No effect on
sexual ability
or feelings.
• Provides long
term
contraception
• Very effective
after 20
ejaculations or
3 months.
• Must use
condoms for 3
months.
• For Women
Female
Sterilization
(Tubectomy)
A permanent method for
women who decide not to
have any more children
• Safe
Simple surgery
•• No effect on
sexual abili ty
• The surgery
may cause
some short
term
or feelings.
Very effective
•• No effect on
sexual ability
complications.
or feeling
• No long term
side effect.
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Questions:
1. What is planned parenthood?
2. What are the methods of contraception?
3. What is LAM and what are its advantages? Whom is it appropriate for?
4. Name one chemical contraceptive and its mechanism of action.
5. Name one non-hormonal contraceptive and its method of usage.
6. What are the advantages of using Condoms?
7. . What are the contra-indications for using IDCD?
8. List out the side-effects of oral contraceptives.
9. What is the timing for Injectable Contraceptives?
10. What are emergency contraceptives? What are the indications and methods available
for the same?
11. Mention the types of permanent contraceptive methods and their further subtypes.
12. What are the precautions necessary after Vasectomy?
13. Who are eligible for permanent contraception?
14. What are the main contraceptive methods that can be used immediately after delivery
of baby and why?
15. Mention true or false:
a) Condoms prevent the transmission of RTIsISTDs
T/F
b) A woman must have her first child before she is
20 years old
TIF
c) mCDs prevent pregnancy by inhibiting ovulation
TIF
d) mCDs can be used by breast feeding mothers
TIF
e) Saheli is started on the first day of the
menstrual cycle
TIF
f) OCPS decrease the blood loss during menstruation
TIP
g) Injectable contraceptives can be taken by a breast
feeding mother
TIF
h) Vasectomy decreases male libido
TIP
i) Vasectomy is effective immediately after operation
TIF
j) Tubectomy is irreversible
TIP
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Delivery of RCH Services and Quality of Care
~ Learning Objectives
• Identify the main target groups of beneficiaries of the RCH programme
• List the package of RCH services
• Describe the weaknesses in the MCH and FP service delivery system and the reasons
for underutilisation of MCHIFP services
• Conduct community needs assessment survey before planning their RCH
service delivery strategies
• Develop and implement RCH service delivery action plans specific to the needs of
the communities
~ Teaching Aids
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Reproductive & Child Health Care
Introduction
Providing good quality services is essential for effective implementation of any Reproductive
Child Health (RCH) programme. Every individual expects good quality of care when seeking
health services. Quality of care had earlier not been given adequate attention in the Family
Welfare Programme. This is one of the reasons why people had not availed the services to the
desired extent. Quality of care (QOC) ensures satisfied clients, who, in turn, come back for
further services. Thus, delivery of good quality care by health workers will determine the
overall success of a programme. Quality of care is not a one-time effort. It is an ongoing
process. Quality Care means "Doing the right thing the right way". It is not enough to have
widespread coverage of the population by maternal and child health services. It has been
found that morbidity and mortality will continue if the quality of care and services available
are sub-standard.
Main Target Group For RCH Services
Package of Minimum RCH Services for the
Target Groups
The RCH package of services must be tailored according to the community needs and the
capacity of the service delivery system.
For each of the target groups mentioned above, a package of services has been identified.
These are:
A. Minimum RCH Package of Services for Pregnant women
& Mothers
• Identification & Registration - Identification registration of all pregnant women should
be done within 12 weeks .
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Delivery of RCH Services and Quality of Care
• Immunisation - Pregnant women must be given two doses of tetanus toxoid
immunisation at an interval of one month.The last dose must be given atleast one
month before the expected date of delivery.
================r.0l===========~Module-6
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Reproductive & Child Health Care
• Prevention and treatment of anaemia - All pregnant women must be provided
supplementary iron in the form ofIron folic acid tablets (large). One tablet is to be
taken daily, with water, starting from 2nd 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, at or before 20 weeks of pregnancy
~ 2nd check up at 32 weeks
~ 3rd check up at 36 weeks.
Antenatal check ups should include routine blood examination, including ABO/Rh
typing, urine examination for protein and sugar, blood pressure and weight monitoring,
and detecting complications .
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Delivery of RCH Services and Quality of Care
• Promotion of Institutional delivery. Complicated pregnancies like twins, women
with high blood pressure, pre eclampsia, diabetes, etc, must be referred to the nearest
referral units for institutional delivery.
• Delivery by trained personnel· Deliveries should be conducted in a safe and
hygienic surrounding. The '5 cleans' must be followed at the time of delivery.
(Please refer to Module IV)
• Management of Obstetric Emergencies· Obstetric emergencies should be identified
at the earliest and referred to the First Referral Unit (FRU) 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 child births
must be encouraged by offering a choice of contraceptive methods.
B. Minimum RCH Package
and Children
============================0~::::::::::::::::::::::::::::::::::::::=MOdule-6
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Reproductive & Child Health Care
• Essential new born care - The baby should be kept warm to prevent hypothermia.
Checking the baby's weight and putting the baby to the mother's breast is important.
Babies born with complications should be referred to the nearest Neonatal Intensive
Care Unit. Babies that are premature or have low birth weight should be provided
specialised care.
• Exclusive breast feeding - Exclusive breast feeding should be promoted during
the first 3 months, and good weaning practices should be followed from the fourth
month onwards .
.•t.t\\'PFI ====================================~0-- -- -- --:-- -- ---- -- -- -- -- -- --:-- ----
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Delivery of RCH Services and Quality of Care
• Immunisation - BeG, Polio, DPT and measles vaccines should be administered to
the infant as per the National Immunisation Programme Schedule to guard against
six killer diseases. (Please refer to Module IV).
• 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.(Please
refer to Module IV.)
• Appropriate diarrhoea management - Parents must be informed about the correct
management of diarrhoea and oral rehydration therapy (ORT). (Please refer to
Module IV)
• Appropriate ARI management - Acute Respiratory Infections (ARI) in children
should be detected early and referred to the nearest health centre at the earliest.
(Please refer to Module IV)
• Treatment of anaemia - Anaemia should be detected early and Iron Folic Acid
tablets (IFA) should be given. Severe cases of anaemia should be referred to the
nearest referral unit.
===========================~0:=====================MOdule-6
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Reproductive & Child Health Care
C. Minimum RCH Package of Services for Couples Eligible for Family
Planning
• Promotion of contraception - Couples eligible forfamily planning should be given
a choice of spacing and permanent methods to choose from (Cafeteria Approach).
• MTP (Medical Termination of Pregnancy) - Safe services for medical termination
of pregnancies should be ensured to women desiring abortions.
• 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.
D.Minimum RCH Package Of Services for Management of
Reproductive Tract Infections/ Sexually Transmitted Diseases
• A large number of people, particularly women, suffer from Reproductive Tract
Infections (RTIs) and Sexually Transmitted Diseases (STDs). RTIs/STDs, if
untreated, may lead to several complications, including infertility.If a pregnant
mother has an RTI or STD, it can affect the growth of her child. People suffering
from such infections should be identified and referred to the nearest health centre
to prevent abortions and congenital malformations.
• Raise awareness of RTls/STDs - The focus should be on information and
counselling to raise awareness of RTIs/STDs. It should be the responsibility of all
recognised service providers to disseminate wider information on RTIs/STDs to
help early detection and treatment.
.l.tlt.l.PF1=================!01===========
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Delivery of RCH Services and Quality of Care
• Management of RTIs/STDs - Early treatment of RTls/STDs would prevent
complications. Patients should be referred to the nearest specialised health facility
for early detection and treatment.
• Treatment of Infertility - Cases of primary or secondary infertility must be sent to
the nearest specialised health unit for treatment.
E. Minimum RCH Package of Services for Adolescents
Adolescents are 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 realise that no single package can be appropriate for all the states,
districts and communities. Variation in needs of the people and in 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.
Weaknesses in the Service Delivery System and
Reasons for Underutilisation
In 1998, a team from the World Bank reviewed several Indian studies dealing with problems
of under-utilisation of mate mal and child care services, that had been planned extensively and
at a high cost. The review concluded that under-utilisation of available MCH and family
welfare services was due to several reasons, some of which are listed below:
~ 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
=============================0!::============~~:_-----_-_--=Module-6
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Reproductive & Child Health Care
• 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, like school teachers,
private doctors, other NGOs
=> No linkages developed with government staff
=> Lack of continuity of care
=> No community-based facilitators
=> Lack of technically qualified staff, especially female doctors
=> Lack of equipment and blood transfusion facilities
=> Shortage of drugs and supplies
=> No standard guidelines
=> No updating of service providers' skills
=> Lack of counselling skills
=> Rude behaviour of staff
=> Lack of gender sensitivity
=> ANM not having plan of action of MCH & family planning services
Quality of Care (QoC) would be much easier to achieve if demand for quality improvement
came not only from the top but from the population being served. This means clients developing
their capacity to ask questions and express opinions.
Ensuring Quality of Care in the RCH Programme
The deficiencies in our health service delivery system have been many and complex, demanding
a complete change.
The new concept of Reproductive & Child Health (RCH) has not only effectively plugged the
above discussed deficiencies, but has also made the health services delivery system most
effective and useful for the beneficiaries. The service delivery system in the new RCHC
approach is best described by the following statement:
.l.ttt.l.PF1 ===============:@~=~~================
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Delivery of RCH Services and Quality of Care
'The RCH approach reorients the provision of services to make these client centred, demand
driven, high quality and based on the needs of the community assessed through decentralised
participatory planning and target free approach.'
Correct approach
Careful
The brief description given above needs further clarification to fully appreciate the salient
features of the RCH approach and its delivery system. Some of these are discussed below:
• This approach 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 morbility, mortality and high fertility,
which had earlier not received adequate focussed attention in the health services
deli very 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.
======"=-"=-"=-"=-"=--=--=--=--=--=--=-------------- -- -- --=0---------------------------------------- _-Module-6
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Reproductive cl. Chilif.lJealt/:l:fiare
• The process of planning helps in estimating the realistic workload of the auxilliary
nurse midwife (ANM), the supply of medicines, vaccines and facilities and also helps
in prioritising the services.
• This need based process works as an in-built mechanism for increased utilisation of
services. Advanced realistic planning also helps in providing quality care.
• It increases the range of services to be delivered under RCH care by including hitherto
neglected areas of RTIslSTDs 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 is the
provision for improving and updating the skills of service providers at all levels; adequate
provision of drugs, medicines, equipments, physical facilities and kits; ensuring effecti ve
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 child birth is attended to by a person with midwifery skills
and that delivery takes place in clean surroundings.
• In the area of family planning, improved qualityand quantity ~f contraceptives are ensured.
Increased opportunities to the client for choosing contraceptives has been provided .
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• The approach focusses on increased male involvement and promotes the use of male
contraceptive methods.
• The approach recognises the importance of IEC in disseminating ipformation about
family welfare and MCH services. The emphasis of the IEC programme is now to
promote beha vioural change through appropriate counselling/interpersonal
communication techniques.
• The RCH approach encourages identification and training of community based RCH
facilitators to supplement the health workers' IEC 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.
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• The approach encourages panchayat members to undertake social marketing of
contraceptives and to implement selected health interventions in their areas.
Communities and Panchayats can playa crucial role in improving quality, availability
and utilisation 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.
=> Promoting informed choice
=> Providing need based service delivery
=> Providing follow-up care
• Inter - personal 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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~ Using good quality equipment and drugs
~ Maintaining high standards of hygiene
.:. 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% of members
are women.
Ten Golden Rules to be followed by the Health Care
Provider to ensure Quality of Care
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RCH in Urban Areas
Rapid urbanisation is leading to large-scale migration to the cities. Migrants move to the
cities in search of employment, leaving behind their dwellings under, open spaces, and strong
social ties in the village. In the cities, they live in slums under unhygienic living conditions
where basic amenities like water and toilets are not available. Slums are not only characterised
by a poor quality oflife, they are also breeding grounds for diseases that endanger the health of
the residents.
It is estimated that roughly 9 crore people reside in urban slums in India and in some of the
metropolitan cities like Delhi, more than 30 per cent of the city population is residing in
slums. Any slum population is burdened by a large family size, high birth rate and high infant
and maternal mortality rates. The incidences of diarrhoea, malnutrition, scabies, and deaths
due to vaccine preventable diseases are also much higher amongst the slum population.
So far, the focus of the health care system, which is based on the primary health care approach,
has been on rural areas. Consequently, the urban health infrastructure has been neglected and
is inadequate. In urban areas, people usually rely on health services offered by municipal
corporations and town administrations. Growing number of migrants are putting increased
pressure on the already overburdened urban health care system.
Family Welfare Centres and Urban Health Posts have been created to provide services to the
slum dwellers. The population served and the staffing pattern of urban Family Welfare Centres
and Health Posts is as foHows:
Population Covered
Staffing Pattern
10,000 - 25,000
25,000 - 50,000
More than 50,000
ANM-
1
FP Male Field Worker -
1
FP Extension Educator /LHV-
1
FP Field Male Worker -
1
ANM-
1
Medical Officer -
1
LHV-
1
ANM-
2
FP Field Worker (M) -
1
Store Keeper-cum-Clerk -
1
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If thepopulation of an area is more than 50,000, it is divided into sectors of 50,000 population
and a Health Post is provided in each sector.
The Urban Family Welfare Centres and Health Posts provide comprehensive integrated services
of MCH and Family Welfare as well as outreach services. The referral support for these centres
comes from the nearest hospital and Post Partum Centres. The Urban Family Welfare Centres
and Health Posts are to function in close coordination with anganwadis (ICDS) and urban
basic services (UBS) centres in their respective areas.
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Questions
a. Pregnant women must be given
treatment of anaemia.
for prevention and
b. Pregnant women must be given a minimum of
ante natal check ups.
(number)
c. A minimum of
(number) post natal check ups should be given
to mothers after delivery.
d. Exclusive breast feeding must be ensured for the first
_
months, following which weaning should begin.
e. A gap (Spacing) of at least
between successive childbirths.
years must be ensured
f. Treatment of anaemia and referral of serious anaemic cases must be made
to
_
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Quality of Care
Theprovision of sell'lces must be
Client-centred
Demand driven
High quality
Based on the needs of the community
Assessed through decentralised participatory
Planning and
A target-free approach
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Information Education & Communication
INFORMATION EDUCATION & COMMUNICATION
"Even as a honey bee
collects honey from the
flowers, small or big, even
so man should cull knowledge
from the big and the
small"
Avadhuta Gita - II
Bhagvad Gita
r;B= Learning objectives
On completion of this module, the participants will be able to :
• Introduce and improve health oriented individual life style to promote greater
responsibility and awareness on health issues, including reproductive health, and
gender equity.
• Encourage attitudes in favour of responsible behaviour, especially in areas of family,
sexuality, reproduction, gender and racial sensitivity
• Enhance the ability of couples and individuals to exercise their basic right to decide
freely and responsibly on the number and spacing of their children
• Incorporate/ develop innovative lEe mechanisms to facilitate adequate reproductive
health programmes.
• Address the needs of the community people more effectively
• Design messages that are at the centre of the reproductive health agenda.
• Reinforce information through a variety of channels, on a regular basis, to create a
mindset.
~ Teaching Aids
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Introduction
Effective information, education and communication (IEC) are prerequisites for sustainable
human development and for bringing about the required attitudinal and behavioural changes.
Effective information, education and communication activities are carried out through a range
of communication channels, from the most intimate level of interpersonal communication to
traditional folk arts to modern mass entertainment, interaction with local community leaders
and coverage of issues by national and international news media.
At the core of successful IEC programmes are good interpersonal communication and
counselling skills, particularly in the context of reproductive and child health care.
Information is perhaps the most powerful asset available to people, one that opens up new
possibilities for the exercise of both rights and responsibilities. This perspective on information
is the heart of what population professional call "IEC"; it is also the basis for the chapter on
these issues in the ICPD's Programme of Action.
Reproductive Health
At the Cairo Conference, out of the understanding of the child and women related problems,
the term Reproductive Health emerged. The concept and components of reproductive health
have been dealt with in great detail in Module 4.
In line with the definition of reproductive health, reproductive health care is defined as the
package of methods, techniques and services that prevent threats to reproductive health and
solve reproductive health problems. It also includes sexual health, the purpose of which is to
bring bliss and happiness in intimate personal relations, and not merely counselling and care
related to reproduction and sexually transmitted diseases.
The vision of reproductive health embodied in the ICPD 'Programme of Action', implies that:
• every sex act should be free of coercion and infection,
• every pregnancy should be intended, and
• every birth should be healthy.
Role of IEC post ICPD
Reproductive health IEC programmes should place a high priority on meeting the growing
demand for family planning through safe access to a range of contraceptive methods. Access
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to contraceptive services should be expanded through clinical and non-clinical channels,
including during postpartum care, and in conjunction withSTD prevention services. IEC teams
should ensure high quality care to men, women and children. This should include :
• access to a choice of methods
• information given to the clients, including counselling, communication
• interpersonal relations between provider and client
• appropriate constellation of services, meaning the availability of related health care
services as well as family planning; and
• follow-up and continuity of services.
Reproductive Health Approach And lEe
In deciding which reproductive health services to offer in addition to family planning,
programmes must focus on activities "that will benefit the most women at an affordable cost
and tht highest public health impact" .
Reproductive health campaigns should address the following components:
Each year millions of women suffer life threatening, chronic, or other serious health
problems resulting from pregnancy and childbirth. Yet adequate delivery care remains
an exception rather than the rule. Because delivery care services are so few, pregnancy
is often the most hazardous activity women in developing countries undertake. Hence,
prenatal, postnatal care and prevention of illegal abortion has also been taken under the
umbrella of RCH.
=> prenatal and postnatal care and safe delivery,
=> breast feeding, and
=> prevention of illegal abortions.
Principally, abortion should be "safe, legal, and rare." Family planning programmes
should work with abortion providers to ensure easy availability of post abortion family
planning services and counselling. Family planning programmes can also educate
women about the importance of obtaining abortions as early as possible in pregnancy.
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Symptoms of STDs may not appear until an advanced stage of the disease. If left
untreated, STDs in women can result in pelvic inflammatory disease, chronic pelvic
pain, cervical cancer, ectopic pregnancy, sterility, and even death. Untreated STOs
greatly increase the risk of contracting AIDS. STDs in pregnant women can cause
stillbirth, congenital malformations and diseases, infant blindness and infant death.
Family planning clinic visits can be opportunities to combat STDs and AIDS by
informing, protecting, screening and treating clients.
Further, the success of Reproductive & Child Health programmes, to a great extent,
lies in effective me. Information, Education and Communication programmes and
improvement in counselling are needed, even where family planning programmes are
well established. Providers, clients and potential clients still have gaps in knowledge
about how to use contraceptives and the advantages and disadvantages of the methods
available. Better counselling, informed choices, and high-quality services will build
trust and create effective demand for family planning.
Greater public knowledge, understanding and commitment at all levels, are vital to the
achievement of the goals and objectives of the present 'Programme of Action'. In all
countries and among all groups, Information, Education and Communication activities
concerning population and sustainable development issues must be strengthened.
What is lEe
Population Information broadly relates to the relationship between rapid growth of population
well being. It covers a wide array of subjects ranging from facts about population growth rates
and their effects on society, health benefits of family planning, family planning methods to
prevention of sexually transmitted diseases including HIV /AIDS. Population information also
includes more complex material on health needs and risks throughout the life cycle and issues
related to population and environment. Such information enables individuals to better understand
the issues, and to participate more effectively in the decision-making process in their community
and country.
Population Education is an indispensable tool for the improvement of the quality of life.
Education is a means to enable the individual to gain access to knowledge, which is a
precondition for coping, with today's complex world. Reduction of fertility, morbidity and
mortality rates, empowerment of women, improvement in the quality of the working population
and promotion of genuine democracy are largely assisted by progress in education. Increase in
education of women and girls contributes to greater empowerment of women, to a postponement
of the age of marriage and to a reduction in the si.ze of families. When mothers are better
educated, their children's survival rate tends to increase. Population education will enable both
men and women to conduct themselves more responsibly in deciding their family sizes, and to
understand the needs of each other to become healthy members of the society.
To be most effective, education about population issues must begin in primary schools and
continue through all levels of formal and non-formal education, taking into account the rights
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Information Education & Communication
and responsibilities of parents and the needs of children and adolescents. Where such
programmes already exist, they should be reviewed, upgraded and broadened with a view to
ensuring adequate coverage of such important concerns as gender sensitivity, reproductive
choices and responsibilities, and sexually transmitted diseases, including mY/AIDS. To ensure
acceptance of population education programmes by the community, population education
projects should emphasize consultation with parents and community leaders.
Communication is the ability to clearly express one's thoughts, feelings, beliefs, opinions,
reactions, values, hopes and dreams - it is a skill that must be learnt. A person's ability to
communicate can have a direct effect on self-esteem and the quality of relationships with
others. Good communication skills can help a person learn more about the self and others.
Poor communication can cause misunderstanding leading to feelings of anger, mistrust and
frustrations in relationships with teachers, friends, family and others.
Communication refers to the transfer of information from one person to another. It includes all
the different ways people use to send and receive information: conversation, letters, books,
television, radio, computer bulletin boards, movies, public speeches, personal actions,
newspapers, body language, signs, and other symbols. Communication can be verbal, non-
verbal or both.
Following are the five components of communication:
The person who sends the message- Sender
Message from the sender - Message
Medium used to send the message- Media
The person who receives the message - Receiver
Feedback from the receiver - Feedback
Sender ~
I I Nucleus
Message
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Modes of communication
• One -Way Communication
One -way communication goes only from the sender to the receiver. In one-way
communication, a speaker believes what (s)he says is right.
One - way communication causes two major problems:
Second, the receiver resents always being told what to do.
Authoritarian supervisors use one-way communication much of the time. They seldom
ask questions to see if one really understands the message.
Two-way communication goes back and forth between the sender and the receiver. In a
two-way communication, the receiver of a message actively participates in the
communication. (s)he listens to the message, (s)he asks question to be sure he/she
.understands, and he/she adds his/her own information, ideas, and opinions. This added
information is feedback. Feedback distinguishes one-way communication from
two-way communication.
Two-way communication means that the sender and receiver work together to achieve
understanding. It means an active role for the receiver, who has the responsibility to provide
feedback to the sender. If the sender does not get good feedback, two-way communication
will not be effective. Effective communication depends on two-way communication. Two-
way communication depends on active listening. Therefore, active listening is called the
secret of effective communication. While communicating, special emphasis should
be on:
• Sequencing the message
• Clarity of the message
• Emotional content of the message
• Simplicity of the language
• Audience involvement
Types of Communication
The use of words and language to convey a message is called verbal communication. Most
people communicate by talking. They must learn to send messages that accurately describe
to a listener what they think, how they feel and what they believe .
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People often communicate without using words. Non-verbal communication - using
symbols, signs, or body language to convey a message- can sometimes tell others
more than the words that accompany it. Non-verbal cues provide additional information
that can help clarify the verbal message.
Body language is another form of non-verbal communication. As one speaks or listens,
one also gives messages with one's body. The way one sits, stands or walks, facial
expressions, body movements are all clues to one's thoughts and feelings. The way
one dresses may tell others about his/her profession, activities, and sometimes, one's
attitudes and beliefs.
A person's posture often indicates how (s)he is feeling. For instance, dragging the feet
and sagging the shoulders while walking sends out a message that conveys that the
person is sad or upset. Slumping at one's desk conveys the message that one may be
tired or bored, while sitting up straight, leaning forward and looking at the speaker
gives the message that one is interested. A person who is tense and nervous may sit
very rigidly.
People may raise their eyebrows, shrug their shoulders, cross their arms, or use hand or
facial gestures while seeing a message or in response to something they have heard. It
is difficult to give a verbal message without accompanying body language. Therefore,
it is important to become aware of non-verbal messages and be sure that these messages
do not contradict the verbal message.
Problems in Communication
• Inaccurate or incomplete messages
• Age or social barrier
Two-way communication may be difficult when the sender and receiver have a very
different status.
• Filtering
People have biases. They see things from different points of view. Sometimes these
biases interfere with communication. One needs to filter these biases. Supervisors
must be aware of their own biases and should always try to see the other person's point
of view.
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• Leaving someone out of a communication
Sometimes a person is left out of a discussion or meeting that affects hislher work.
(S)He misses an important message, and hislher work suffers.
• Lack of acceptance
Sometimes a person simply refuses to respond. (S)He hears only what he/she wants to
hear. Perhaps (s)he does not trust the sender, or he/she is in a bad mood. Perhaps (s)he
does not agree with the message.
Some people do not pay attention to messages. They do not read instructions carefully.
They do not listen carefully.
• Poor memory
A person may communicate a message well, but the receiver may forget it.
When a person is given too much information, (s)he may forget some of it. A supervisor
who wants to communicate effectively must be careful to keep the message simple. Do
not include unnecessary details that may confuse the person receiving the message.
Importance of lEe
Information, Education, and Communication (lEC) activities bring people and family planning
programines together. Communication activities give people the information they need to make
informed choices about using and continuing to use contraception and about other aspects of
reproductive health. In family planning, as in many other development activities including
health and agriculture, communication campaigns create awareness, increase knowledge, and
build public approval of new ideas and practices.
Family planning use depends on people's private decisions and actions. These decisions involve
individuals, couples, families, and even peer groups. It is not enough for service providers to
know about family planning. Everyone, involved in making family planning decisions,
especially women, need accurate and full understanding.
People obtain information about family planning both from the mass media and through
interpersonal communication. Radio and television reach millions of people even in remote
areas and are a powerful influence on opinions, attitudes and behaviour. People also hear
about family planning in schools, social programmes, and communities. Even street plays and
nukkad nataks have brought family planning topics to rural people lacking access to radio
and television .
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Interpersonal communication, whether among family members and friends or between service
providers and clients, plays an important role in people's decisions about family planning,
helping people decide where, when, which methods and how to use family planning. After
exposure to mass-media coverage of family planning, people typically discuss family planning
with friends or relatives, or they make contact with a provider promoted in the mass media,
such as clinics, a CBD worker or a counsellor.
Planning Communication Projects
Communication programmes are most effective when they are planned strategically and follow
a systematic focussed plan of action. Johns Hopkins University/Population Communication
Services (JHU/PCS) uses a strategic planning process called the "P-Process", which organises
the planning and implementation of a communication programme into progressive stages. The
Process provides a framework for strategic development, project implementation, technical
assistance, institution-building and training. This process applies to men's participation
in programmes.
The "P", a diagram of the communication project planning process, is an effecti ve tool for
designing and implementing health-related programmes. It may look deceptively simple, but
carrying out a programme using this approach requires a lot of work. Experience has proven,
however, that the more a communication programme respects these steps, the greater are its
chances of success.
The "P"
Steps in the
Comroonlcation Project Process
Adapted IHU/fOpulation Communication
Services (117)
Communication Project Planning Process
• Analysis
=> Problem assessment and situation analysis:
=> Find out as much as possible about the existing situation before designing the
communication programme.
=> Identify potential audiences
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~ Assess
The social and demographic context
Prevailing knowledge, attitudes
Practices regarding the specific health issue to be addressed by the programme
Ethnic and linguistic affiliation
~ Review existing health facilities, organisational resources, and communication
infrastructure
~ After analyzing the situation, prepare a document presenting the situation and
recommendations for action
• Design
~ Specify communication objectives
~ Determine target audience(s)
~ Decide message, content, media channels and mix
~ Establish a plan for coordination among media channels
~ Outline an overall action plan
~ Create a strategy
~ Define stages
• Development, Pretesting & Revision
The analysis and design conducted during the first two stages should guide this
next stage.
~ Be sure that messages are simple, clear, specific, positive and action oriented
~ Pretest messages and materials with their intended audience
~ Materials assessments should be based on attraction, comprehension, acceptability,
self-involvement and persuasiveness/believability
• Implementation, Monitoring & Assessment
Implementation
~ Identify, implement, and monitor key elements of the project
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~ Inform key personnel of the implementation schedule
~ Disseminate messages through appropriate channels
Monitoring
~ Verify the amount of materials produced
~ Determine whether the work schedule and budget are being followed
~ Strengthen relationships with other agencies
~ Modify project design as necessary
~ Measure the impact of the project on the target audience in terms of the stated
objectives
~ Measure changes in knowledge, attitudes and/or practices.
• Review and Re-plan
~ Reanalyse the situation in the light of the effects of the communication project
~ Design the next phase of the project
~ Adjust to the changing needs of the audiences and build systematically on past
experiences
~ Make the communication project, planning process a continuous one.
The P-Process ensures that material and activities were tailored to the intended
audience, appropriately designed, efficiently disseminated, and evaluated for impact.
The Process begins with a careful review of the audience and assessment of current
policies, programmes, and reproductive health services available and analysis of
communication resources. Formative research, audience segmentation and
pretesting help to ensure that a project's outputs are appealing and that messages
are readily understood.
Steps to Behaviour Change Model
• Knowledge
=> Can recall family planning and other reproductive health messages
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=> Responds favourably to reproductive health messages
=> Discusses messages or issues with members of personal networks (family, friends)
=> Thinks family, friends, and community approve of practice
=> Approves practice
=> Recognises that specific health practices can meet a personal need
=> Intends to consult a provider
=> Intends to practice at some time
=> Goes to a provider for information/supplies/services
=> Chooses a method to practice and begins use
=> Experiences and acknowledges benefits of practice
=> Advocates the practice to others
=> Supports community programmes
Sex Education and Communication
All sex educators need to communicate with care and efficiency. Sex educators are the first to
admit that talking or writing about sex is difficult. The function of sex education by the health
educators is to inspire confidence in the client, in a spirit of confidentiality, breakdown prej udices
and develop a healthy attitude towards sex and so become an empathetic observer.
Parents, teachers and the public at large are still skeptical and apprehensive about the full
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implication of sex education. Sex is still a taboo and not a subject of open public discussion.
Regional sex terminology is not yet standardized; sex language is a great barrier in
communicating news, views and imparting scientific information on sex and sexuality.
Parents, especially mothers, observed that in this male dominated society, the girls suffer most
and become the victims of the erratic and irresponsible behaviour of men. Girls should not
remain ignorant of the basic facts of life, about sex and sexuality. Girls need scientific
information regarding growing up problems, menstruation, human reproduction and human
sexual behaviour. Girls should be educated on a priority basis.
If a parent makes a child comfortable when talking about sex by encouraging questions from
the very beginning, it becomes easier to discuss deeper issues as (s)he grows up. And (s)he
will continue to turn to them for interpreting experiences and ideas. This is how ground work
for trust and meaningful communication is laid.
Sex is a very sensitive area. Its education has to be done sensibly. In implementing it, the
general public have to be taken in confidence. Public contact through discussions with small
groups goes a long way in putting the programme on a sound footing and spreading its message.
Feedback makes the programme more realistic and valid. It is eventually public acceptance
that declares the objectives are being met. IEC activities must be planned keeping in view the
following facts:
• Adolescents are particularly at risk because of their lack of knowledge and their lack of
resources. The information they get from their peers tends to be limited and inadequate.
They often get bad advice.
• Child to child and youth to youth education activities are often the most successful.
• Developing decision-making skills and income-generating activities help address other
health-care problems, especially many kinds of substance abuse.
• Education of adults, including parents, teachers and health providers is as important as
education of adolescents.
Male Participation
While often neglected in the past, men are an important audience. Providing information,
education and communication (IEC) about reproductive health is the key to gaining their interest
and support. Provider experience of the last decade demonstrates that communication can
change men's health behavior.
The movement to include men in reproductive health has many names, including men's
participation, men's responsibility, male motivation, male involvement, men as partners and
men and reproductive health. In this module "men's participation" has been used to describe
men's active and positive involvement in achieving good reproductive health.
Programme experience with men's participation yields many lessons. The following lessons
learnt can help policy-makers to formulate IEC programmes more effectively:
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• Reach Male Audience with Appropriate messages
=> Build on men's approval of family planning
=> Use the mass media to communicate with men.
• Use Communication to Promote Behaviour Change
=> Understand the influence of gender
=> Encourage couple communication
=> Bring information to where men gather
=> Inform men about condoms and vasectomy
=> Counsel men with respect and sensitivity
=> Offer men a range of health services
Reach Male Audience with Appropriate Messages
• Build on men's approval of family planning
More men probably would take better care of their own reproductive health and that of
their partners if programmes reached out to them with appropriate information. A number
of programmes are finding ways to do that. Concerned about the spread of HIV /AIDS,
the Transport Corporation of India, in collaboration with the AIDS Control and
Prevention Project, in 1995 launched an IEC project for the truck drivers. Community
educators found thousand of truck drivers much more receptive about reproductive
health services than they had expected .
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One proven way to reach and inform men is through the mass media. Mass media can
expose male audiences to messages that can influence their reproductive health
knowledge, attitudes and behaviour. Often men are more exposed to radio and television
than are women, probably because men generally have more free time, more education,
more disposable income and in many cultures, more freedom of movement than women.
• Reach out to young and unmarried men
Programmes need to address young men's reproductive health issues, including STDs,
contraception, unwanted sex, and unintended pregnancies.
To help prepare boys and young men to become more responsible sexual partners and
spouses, programmes can offer relevant information about sexuality and reproductive
health, including the risk of STDs and how to avoid them. Young men also need
encouragement to delay sexual activity until they are better prepared to cope with their
own and their partners' emotional and health needs.
Entertainment format and the mass media can be powerful ways to reach youth with
reproductive health information. Some youth programmes have found that peer
educators can reach groups of adolescents with reproductive health information.
TAKING CARE OFYOURSELF ISYOUR DECISION
DON'T YOU THINK IT'S WORTH IT?
• Understanding the influence of gender
Gender has a powerful influence on reproductive decision-making and behaviour. In
many countries men are the primary decision-makers about sexual activity, fertility,
contraceptive use, breast feeding and seeking prenatal care.
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An awareness of gender offers a new way to understand the complex relationships,
between men and women, that affect their reproductive health behaviour. IEC campaigns
can promote new gender roles for men.
The ICPD Programme of Action encourages reproductive health care programmes to
move away from considering men and women separately.
It also draws attention to the unfairness inherent in many men's and women's gender
roles, calling men to take more responsibility for household work and child -rearing.
• Encourage Couple Communication
Couple, or spousal, communication can be a crucial step towards increasing men's
participation in reproductive health. Communication enables husbands and wives to
know each other's attitudes toward family planning and contraceptive use. It allows
them to voice their concerns about reproductive health issues, such as worries about
undesired pregnancies or STDs. Communication also can encourage shared decision-
making and more equitable gender roles.
Sometimes, however, communication between partners may not be desirable. For
example, a women may use contraception covertly because it would be unwise and
even dangerous for her to inform or try to involve her partner. Counsellors need to
assess carefully the reasons for covert contraceptive use and appropriateness of
encouraging spousal communication.
• Bring information to where men gather
Programmes can reach more men when they go where men naturally congregate, such
as the workplace, social clubs or sporting events. Men are comfortable in these places,
form a ready audience and may be more receptive to new information. The success of
many contraceptive social marketing programmes over the years testifies to the validity
of this direct approach.
• Inform men about condoms and vasectomy
Men need information about contraceptive methods. When they know the facts about
male methods, they are more likely to use them. Providers need to offer sensitive
counselling to men, whose concerns often differ from those of women. Men are more
likely to use reproductive health services that are part of a range of services that
interest them .
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participation, providers can go beyond answering men's questions about contraceptive
methods and also help them consider their reproductive goals, those of their partners
and the choices they face together.
Some men, especially young men, do not want to reveal their ignorance about sex and
reproduction. Nevertheless, by being sensitive to men's concerns, educators and
counselors can determine what information they need and convey it without causing
embarrassment.
• Offer men a range of health services
Reproductive health programmes around the world have found that men have similar
reproductive health concerns and needs. "Well Man Screening" approach is therefore
adopted which incorporates constellation of health services, along with non medical
services such as offering job counselling, skill training, legal counselling, etc. to make
it more attractive and comprehensive for them.
.
As the new thinking has evolved, a consensus is forming. To improve women's and
men's reproductive health, policies and programmes must:
~ encourage men to take more responsibility for their sexual behaviour;
~ increase men's access to reproductive health information and services;
~ help men to communicate with their partners and make contraceptive choices
together; and
~ address the reproductive health care needs of couples
Communication Campaigns
In family planning programmes, communication campaigns play many roles. They make people
aware of modern contraception, its proper use and where to find services. They counter myths,
dispel rumours, and correct misinformation about modern contraceptives and family planning.
They also help link family planning to other reproductive health care and to the broader roles
for women. They raise the quality of services by improving the interpersonal relations and
skills of providers and by providing information material for clients and providers.
Communication campaigns work best when they are:
a) Coordinated with service: When services and supplies are not available and people's
expectations cannot be met, generating public interest can destroy the credibility of a
family planning programme. Providing services without effective communication,
however, invites misinformation, effective communication, however, invites
misinformation, rumours and bad advice, from which recovery is difficult.
Many a time, communication campaigns have been seen to promote discussion of
family planning, increase clinic visits and raise levels of contraceptive use. So much
so, the influence of campaigns on radio and television has helped make family planning
a household norm rather than the taboo subject it had been.
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b) Engaging, focused: To help people choose healthy behaviour, communication
campaigns require focus, both as to the audience and as to the message. This focus is
best achieved through careful planning based on audience research. Communication
must suggest to specific audience both what to do and how to do it.
Counselling - An effective tool
Counselling is a specialised process of communication. It is a skill that develops and grows
with practice. Counselling is a professional relationship between a counsellor and a client
whereby the counsellor helps the client to get direction towards dealing with his/her present
and future problems/situations. A counsellor, therefore, must have a clear understanding and
sound knowledge of the subject being discussed and ability to appreciate the specific problems
of the client.
In counselling, clients and providers meet face-to-face to discuss reproductive health problems
and healthy practices. Service providers not only inform their clients but also listen to them
and help them to understand their feelings and needs and thus to make more appropriate choices.
In a good counselling situation, the provider establishes a relationship of trust and confidence
with the client. This relationship is established by expressing empathy(that is, putting oneself
in the other person's position), being respectful, and telling the truth. Counselling is a special
form of interpersonal communication, and most people require training and practice to become
proficient counsellors.
Informed Choice
Family planning counselling programmes are responsible for ensuring their clients' right to
make their own decisions about family planning. Programmes that offer client-centered care
help people make informed decisions about reproductive health and contraception.
To make an informed choice, clients need accurate, clear, unbiased, and useful information
and advice about reproduction, family planning, and correct use of contraceptive methods.
Many people discontinue using contraception because they lack accurate information, while
others never adopt contraception at all for want of information and guidance .
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Counsellor should inform clients about both the advantages and the disadvantages of different
contraceptive methods. Providers should not discourage or promote particular methods at the
expense of others that might interest a client. Once clients have chosen a specific method, they
also need information about proper use, potential sid.eeffects and complications, and the follow-
up services that are available.
Family planning programmes provide clients with information in many ways, including the
broadcast media, print materials, and videos, as well as person-to-person discussion. Mass-
media and interpersonal communication play complementary roles in ensuring that clients can
make an informed choice. Many people can learn about family planning in the mass-media,
and some visit family planning providers as a result. Then, at the clinic or other service delivery
points, the counsellor and client discuss the client's individual questions, needs and concerns.
When people make their own informed choices and get the contraceptives they want, they are
more likely to be satisfied and to continue use.
The Six Steps of Counselling
Family Planning counselling has six steps. One can remember them with the English word
GATHER. The meaning of each step is described briefly here.
G
Greet each client warmly.
A
Ask the client questions about herself/himself.
T
Tell the client about each available family
planning method. Then tell him/her about the
methods that most interest him/her
H
Help the client choose the method that is best
for him/her
E
Explain how to use the method that the client
chooses. Help him/her plan how he/she will
use the method
R
Return for follow-up. Agree on a time to
meet again.
Counselling Your Clients
• Information on Family Planning
You must be well informed about all methods of family planning.
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~ Understanding how your clients feel
~ Talking to your clients in a way that they understand
~ Encouraging your clients to talk to you and ask questions
~ Use "open ended questions" that draw out more information from the client
~ Ask clients what information they have about the methods that interest them
.:. Number of pregnancies
.:. Number of live births
.:. Number of living children
.:. Family planning methods used presently and in the past
.:. Relevant information on general and reproductive health
.:. Keep questions simple and brief and look at your clients as you speak to them
The best counselling is a discussion between two people, not a lecture by one person to another.
In a discussion each person has something to say, and each has something to learn.
To begin ...
• Greet your client warmly,
~ as soon as you meet clients, give them your full attention
~ provide a comfortable atmosphere to sit and discuss
~ be polite, introduce yourself
When a couple visits a clinic they may want to talk about something other than the real
reason for the visit. Thus sensitive Counsellors lead the conversation to reproductive
health topics and ask questions that draw out the couple's questions and concerns.
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~ ask questions to elicit information in a non-confronting way.
~ help clients to talk about their needs, wants and any doubts, concerns or questions
they have.
Tell your new clients which methods are available and where
Address any anxieties or myths that the client may have about any particular method.
A rumour is an information that is passed from person to person, and no one is
sure where it started. Often it is false or inaccurate. False rumours about family
planning are common in some places. They can scare some women away from
asking questions. They can scare some users into discontinuing a method. In these
ways rumours cause unwanted pregnancies. You, being a health worker, have an
important role to stop a false rumour by disseminating correct information about
the methods.
How can You keep Rumoursfrom Starting?
• Remember every family planning method is good for some clients. Your
responsibility is to help each client choose the method that suits her or him
best. This is not necessarily the one that you, the provider, likes best. Always
give clients correct information and make sure that they understand it.
• Encourage your clients to ask questions Tell them to come to you if they
hear something bad about the method they are using. Then you can talk to
them and give them correct information.
• Use the correct words and give all clients the same basic information about
the specific method.
• Be honest about the disadvantages especially side effects. If you are open
and honest, your clients will know that you are not hiding information, and
they will not believe in false rumours.
• Ask your clients what they have heard about the specific method
dispensed to them. Always take their answers seriously. When a client tells
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you rumours that they have heard, do not laugh at them. Talk to them
seriously and honestly.
• Try to find out the source of rum our and why they believe it. Gently
correct mistaken ideas.
• Tell your supervisors about rumours Then your programme
administrators can give you and your colleagues the right answers to correct
the rumours. They can also take pre-emptive measures to stop rumours
spreading to other areas.
Help clients Choose a Method
• Ask clients if there is any particular method they would like to use.
• To help clients, ask them about their family circumstances and their
reproductive intentions. e.g. Till when does the client wish to delay
pregnancy?
• Ask the clients which method their sex partner would prefer (in case the
partner is not present). Some methods are not safe for some clients. When a
method is not safe, tell the client so and explain clearly. Then help the
client choose another method.
• Ask clients if there is anything they do not understand. Repeat information
if necessary.
• Confirm whether the client has made a clear decision. Ask 'have you decided
to adopt a contraceptive method. If yes, which one?'
• Explain how to use a method
=::> explain how to use the method. Show them samples.
=::> give them supplies, if appropriate.
=::> if the method cannot be provided immediately, tell the client how, when and where
it will be provided.
=::> ask the client to repeat the instructions, listen carefully to make sure she or he
remembers and understands.
• Return for follow-up
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method. At the follow-up visit:
~ ask the client if (s)he is still using the method.
~ ask how the client is using the method. Check to see that it is being used correctly.
~ ask if the client is having any side effects, mentioning them one at a time and
cross-checking with the client. If so, find out how severe they are. Reassure clients
with minor side effects that they are not dangerous. Suggest what they can do to
get over them. If side effects are severe, reassure the client and refer for further
treatment. Do not dismiss the problem off-hand even if it appears to be unlikely.
~ if the client is still reluctant to continue to using the method, counsel himlher
about switching to another method.
~ ask if the client has any questions.
Counselling Values
• A belief in the dignity and worth of each individual
• A perceptual view of behaviour
• A tendency towards self-actualisation.
• A belief that people are good and trustworthy.
Counselling skills
Counselling involves more than giving information to a client or a potential client. It is a skill
that develops and grows with practice. Certain techniques are used during counselling in order
to make the client comfortable so that effective communication is facilitated. Before starting
the counselling process, it is necessary to ensure that the physical setting is conducive to
counselling. Counselling skills include a range of verbal and non verbal behaviours that establish
a positive rapport.
• Active listening
Listening is the most important skill a service provider must possess. The counsellor
should pay total attention to what is being said, observe non-verbal messages that the
client is sending and encourage the client to talk by nodding the head and saying
"go on".
Some counselling behaviours representative of active listening are:
~ Good eye contact
=> Head nodding at relevant places
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~ Saying "go on"
~ Not rushing the client during pauses while the client may be finding words to
express oneself
~ Not interrupting when the client is talking
~ Asking question to facilitate conversation.
~ Ask only one question at a time. Wait for an answer.
Ask questions that let clients tell you their family planning needs. Examples are :
"How many children do you want?"
"What does your husband think about family planning?"
~ Avoid asking questions that can be answered by "yes" or "no". Ask question that
encourage clients to say more. Examples are: "What method have you used in the
past?" "What have you heard about injectables?"
~ Use words that encourage clients to keep on talking, such as "then"? "and?" "oh"
~ Avoid asking questions with "why". Sometimes "why" sounds as if you were finding
fault with a person.
~ Ask question in different ways if you think the client has not understood.
~ Avoid repeating questions that the client does not wantto answer.
~ Face the client during the interaction.
~ Do not perform other activities while providing counselling
~ Use an appropriate tone of voice showing that you are not rushed or frustrated.
• Summarising and Paraphrasing
This means restating by the service provider in her own words what the client has said
so far to check whether it has been correctly understood. This indicates to the client
that the provider has been following and understanding what has been said by the
client. For example,
In empathising with a client, the counsellor is able to leave aside his/her own frame of
reference, and, for the time being adopt the frame of reference of the client.
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The counsellor experiences the client's feelings as if they are one's own. Empathy
involves the power of understanding and imaginatively entering into another person's
feelings. There is more involvement than in sympathy, where one shares or experiences
an affinity with the emotions of another. Empathy implies a position of equity between
the counsellor and client. In case of sympathy, the counsellor will be assuming a position
of superiority.
• Positive Regard for the client
The counsellor relates to the client as a person of equal status and accepts that the
client has a right to accept or reject family planning.
Confidentiality is also a part of showing respect for the client and his /her problem.
The counsellor assures the client that no one else will be told about the client's problem.
Being an Effective Counsellor
An effective counselor understands the perceptions of the client and put them at ease and
allows their beliefs and feelings to emerge. By providing information and assurance to clients
or couples, an effective counsellor assists them to make their own decisions. An effective
counsellor is empathetic, honest, respectful, trustworthy, confidential, knowledgeable and has
good interpersonal communication skills.
The Counselling Process
Counselling is an on-going process integrated into all aspects of life and is not just information
presented and discussed at one point in the provision of services. The ability to make decisions
is an integral part of healthy personal functioning. Many problems that clients bring to a
counsellor involve the inability to make decisions. Counsellors aim at giving clients skills to
solve their own problems. This approach facilitates client independence. Many people have
proposed sequential steps:
In order to establish good relationship and environment for counselling the service
provider should greet the client by saying "Namaskar" and "please come in" , and by
offering the client a place to sit. The provider should tell the client that his/her visit to
the clinic will be kept secret.
"What is the problem?" "What prevents solution?" "When and under what circumstances
does the problem occur?" and so on.
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• Identification of values, and goals
During this phase a client's values are examined so that the solution will be consistent
with the clients' values and long range goals.
• Identifying alternatives
A list of possible alternatives is formulated.
• Examining alternatives
At this stage advantages and disadvantages of each proposal are weighed, based on
factual information such as amount of time and money involved.
If the decision is critical and the client is unsure about the choice, the decision may be
tested at this stage. Then further information can be gained and fed back into the decision
making process.
Evaluation should be a continual part of the process. It should be again emphasized
that the role of the counsellor is not to make the clients' decision for them but to give
them the skills not only to deal with the present concerns but also to deal effectively
with future problems.
After having provided the information that the client needs, give a date for a follow-
up. Reassure the clients that they may return at any time if they have a question or
problem, regardless of origin of problem. Ask if client needs any additional information.
If so, provide it. Then bid the client good-bye politely, inviting him/her to come again.
Counselling Adolescents and Youth
The counsellor may come across adolescent clients occasionally. Adolescents need a special
approach as this is the period when they are discovering their sexuality, feeling curious and at
the same time feeling embarrassed about many areas of sexual function. They need accurate
information about the reproductive system, function of various organs and changes due to
puberty. They have misconceptions about menstruation, masturbation and nocturnal emissions,
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all of which are natural processes. In many cases, their only source of information are their
peers, who are likely to be ill-informed. Under family education programme they should be
informed about:
• biological facts about reproduction
• coping with sexual development
• different kinds of birth control methods
• preventing sexual abuse
• facts about abortion
It is necessary to be approachable, non-judgmental and non-threatening when dealing with
adolescents. The counsellor should not be moralistic with adolescents, as in that case they will
never return and will lose their only way of obtaining accurate information that would enable
them to practice safer behaviours.
• Impart timely and proper sex education to adolescents;
• Encourage them to interact with the opposite sex;
• Keep close eye on the child for signs of trouble; and
• Divert their energy in hobbies and sports as far as possible.
Reaching Young Adults Through Entertainment
Young people love the mass-media and entertainment- through radio, television, music, videos,
film, comic books and more. The entertainment media is aimed at young adults, who, even in
many developing countries, often spend substantial amounts on entertainment. Love, romance
and sex are favourite topics of this entertainment and many young people say that this is where
they learn about sex.
What young people see and hear about sex in popular entertainment is often misleading,
incomplete or distorted. Casual or impetuous sex is depicted as acceptable and often as without
risks or adverse consequences such as unintended pregnancy and sexually transmitted diseases.
From most mass-media entertainment, young people learn behaviour that puts their
health at risk.
Efforts are underway, however, to use the mass-media to help young people adopt more healthy
behaviour. These range from comic books that tell youngsters how to avoid HIV/AIDS
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to large-scale campaigns, which, through television, radio, music videos, and telephone hotline
linked to youth assistance agencies, encourage young people to adopt responsible
adult behaviour.
Sexually Transmitted Diseases - Counselling
Take all your medication as instructed even if symptoms disappear or you feel better.
The symptoms may come back if you do not take all of the medication.
Do not have sex again until you take all your medication as directed and you have no
more symptoms. If you do not wait, you may give an STD to your partner. Also, do not
have sex again until your partner is treated.
• Help your sexual partners to get treatment
• Come back to make sure you are cured
If you still have symptoms, you can get more medicine to cure your infection.
• Stay cured with condoms
• Keep safe by staying with just one sexual partner
If you have sex with several people, there is more risk that one may have an STD and
infect you. It is advisable not to have multiple sex partners.
• Protect yourself against AIDS
Go to an antenatal clinic within the fist three months of pregnancy for a physical
examination and syphilis test (VDRL test).
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Performance Observation Checklist
• Health Worker's Counselling Skills With Individual
Mothers
.:. Asks open-ended question about mother's experience
.:. Praises specific action(s) that mother has done correctly
.:. Advises mother about specific she should do next
.:. Asks mother to explain what she has just heard
.:. Praised mother for what she has repeated correctly
.:. Corrects specific messages that mother has not repeated
.:. Asks mother what problems or constraints she might have in carrying out what
the health worker is recommending
.:. Discusses with the mother what she can do to resolve the problem or constraint
.:. Uses appropriate vocabulary ( the specific words selected would be based on
the cultural and linguistic setting)
.:. Asks mother if she has any questions concerning what she has heard or anything
about the health of her child
• Individual Counselling Skills Applied to Immunization
.:. Greets mother
.:. Smiles at mother
.:. Praises mother for having brought her child to the health center to be immunized .
•:. Asks mother if she has any questions about the immunizations or any other
aspects of her child's health .
•:. Explains what side effects might occur form this immunization (if appropriate) .
•:. Asks mother what she will do if her baby gets sick tonight.
.:. Praises mother for what she has repeated correctly .
•:. Corrects specific information concerning side effects which the mother has
not repeated.
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.;. Asks mother what problems or constraints she might have in carrying out this
recommendations .
•:. Discusses with the mother what she can do to resolve the problems or constraint.
.:. Asks mother how many vaccinations the child needs to complete immunization
schedule and specifies the date and time mother should return .
•:. Asks mother what problems she might have in returning to complete the
immunizations .
•:. Praiseslreinforces mother for what she has repeated correctly .
•:. Corrects specific information concerning the number of vaccinations, and date
and time mother should return, that the mother has not repeated .
•:. Uses appropriate vocabulary (Specific words would be based on the health topic
and the cultural and linguistic setting.)
.:. If so, repeats the question mother has asked. Explains answer .
•:. Asks mother what she has heard .
•:. Thanks mother again for coming .
•:. Repeats that she will see her again at the specific time and date the mother
should return.
Mass-Media and Education
There are many ways that family planning organisations can encourage media coverage of
family planning and population matters. In all cases, getting family planning messages on the
air requires providing what the media wants rather than trying to force on the media what
family planning experts want.
Organizations can establish themselves as willing, reliable sources of information and opinions
for news media about family planning and population and can make top executives accessible
to reporters. A prime rule: Never try to deceive the news media.
• Family planning organisation can issue press releases on various topics: the opening of
a new clinic, the completion of new population studies, a policy statement, a response
to a critic.
• They can hold news conferences on especially important stories.
• They can invite broadcasters to cover events, providing background information and
helping them arrange interviews.
• They can volunteer to participate in talk shows. Family planning groups should stay
alert to the development of public debates over sex education in the schools, for instance-
that their staff members are qualified to discuss on the air .
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• They can place public service spot announcements with radio and television stations.
• They can persuade actors, well-known athletes, and other celebrities to endorse family
planning- and then arrange for media coverage. They should make sure in advance that
the audience will find the celebrity's endorsement credible.
• They can conduct media contests- for the best family planning story of the year on
radio, for instance, This gives family planning organisations an opportunity to honour
reporters who have helped family planning and to encourage responsible reporting
about family planning.
A cardinal rule in working with the media is to keep an up-to-date list of all media and media
personnel interested in family planning. Communication efforts for family planning can be
organised in different ways. Funds of course, determines how much can be done. Developing
good relation with existing media and getting as much free coverage as possible is the best
way to stretch scarce resources. Mass media communication requires skilled, experienced
communication professionals.
In the communication marketplace, where so many messages compete for the attention of the
audience, the messages that are heard and heeded are those with the most intimate appeal and
best technical quality. These are best provided by communication professionals.
Achieving Content Quality
• Content quality depends on
Attention arousal material at the start of a programme even a brief spot announcement
should be arresting. "Minute one is the time of decision for the listener", says one
communication expert.
In India, AIDS awareness campaign enacted by well known film actress and social
activist Shabana Azmi is well received by both literate and illiterate audience.
Even sportsmen and various celebrities have widely been utili sed by media to
create awareness on Drug dependence, HIV /AIDS, and Family Planning methods.
Can Mass Media Affect Behaviour?
Mass media can change behaviour in certain circumstances. Mass-media communication is
most successful at changing behaviour when it:
• Is designed to reach a specific group
• Comes from a source - a person or group - that the audience likes, understands,
and believes.
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• Provides a message that is engaging, personally relevant and novel;
• Tells the audience what to do and how to do it; and
• Is coordinated with locally available supplies and services;
• Well-researched mass-media campaigns that are entertaining as well as informative
seem to have the greatest impact.
Indeed, mass-media communication may be a more cost-effective way to influence behaviour
than organised interpersonal communication. Although the impact of mass-media on anyone
individual may be slight, its cumulative effect on an entire population may be great because it
reaches many people.
Conventional wisdom contends that mass media can best create awareness and inform, but
interpersonal communication is more effective at changing behaviour.
Promotion: key to family planning sales
Promotion advertising and other publicity - is crucial to sales for most businesses. Thus it is
crucial for the business side of family planning- for the manufactures, retailer, private providers,
nonprofit family planning organisations and even government services that want to attract
paying customers.
• Designing effective Promotion
Choice of audience comes first; it guides other choices in the design of a promotional
campaign. audience research helps to avoid costly mistakes that can limit the impact
of promotional campaigns.
-+ Message
People are willing to buy a safe, reliable, effective product that gives them greater
control over their lives and improves their self perception. Thus the message must
be persuasively put and arrestingly presented, with good technical quality.
The source - the person speaking in broadcast advertising or appearing in print
promotion - should suit the message.
Intended audience and cost often determine which media to use. Broadcast media
reach the largest audience with the greatest frequency .
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Information Education & Communication
• Different methods of disseminating information to
the clients
-+ Individual
.:. Home visits
.:. Office calls
.:. Personal letters
.:. Technical manuals
.:. Self-learning
-+ Group
.:. Meetings
.:. Study tours
.:. Role plays
.:. Group discussion
.:. Demonstrations
.:. Drama groups/Street plays
.:. Games/Simulation
-+ Mass
.:. Pamphlets
.:. Posters
.:. Newsletters
.:.. Radio
.:. Cinema
.:. Stickers
.:. Stamps
.:. Calendars
.:. Newspapers
.:. Banners
.:. Slogans
.:. Booklets
.:. Television
.:. Internet
.:. Films
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Reproductive & Child Health Care
Effective Communication
The effectiveness of communication can be enhanced if a speaker communicates keeping
following facts in mind:
The opening set refers to the first few sentences of any presentation. It is critical
for the success of the entire communication sequence. It should contain
the following:
.:. Introduction of speaker, i.e. you (indicating clearly why the audience should
listen to you)
.:. Setting of objectives for the time period- by end of this session you will be
able to ...
•:. Motivation of participants- making them very clear why the subject of the
session is important to them .
•:. Description of the expectations of learners- By the end of this session, you
should be able to ..., or, after this discussion, I will expect each one of you to ...
Opening set involves all five components of a completed communication sequence the
SENDER(speaker) the RECEIVER(audience) and the MESSAGE with its METHOD of
presentation. You as the SENDER will complete the cycle by obtaining FEEDBACK from the
RECEIVERS that the message has been understood, they are motivated and know what will
be expected of them.
=> Make effective use of voice and body.
=> Set the mood with an effective approach to the platform
=> Replace physical distraction with purposeful movement
=> Add vocal variety for generating interest and increasing clarity.
=> Include purposeful pauses
=> Maintain effective eye contact
=> Show a desire to communicate
=> Avoid over-dependence on notes
=> End with a strong conclusion
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Information Education & Communication
Let your listeners know that you are a professional.
~ Determine your major purpose for speaking.
~ Adapt your topic selection to the time allowed, your audience and situation.
~ Show evidence of audience adaptation and involvement.
~ Include clarification techniques to make your message meaningful.
~ Pay attention to appropriate, interesting and dynamic language choice.
~ Repeat key ideas for instant understanding and clarity.
• Guidelines for the Message and the Method
~ Capture the audience's attention and interest with an effective introduction
~ Choose an appropriate organisational design for your topic and audience
~ The informative speech should focus on clarity of ideas.
~ The persuasive speech should focus on acceptance of ideas.
~ End your speech effectively- this is a good spot to highlight, review or stimulate.
Audience Adaptation Concept
The major problem, that a speaker trainer faces is adaptation to the specific audience.
In designing your speech, keep the following in mind:
Adaptation to occasion
Adaptation subject
Adaptation of delivery
Adaptation to feedback
Determine the basic function of the speaker-
to entertain, to inform, to persuade. Do not
use anything that may offend.
Simplify the subject for the time allowed and
for the type of audience. Use simple terms and
explain unfamiliar terms. Use the background
of the audience.
Adapt the loudness and slower tempo for a
larger audience. Slow down for complex or
new concepts.
A speaker should also adapt to the feedback
(both verbal and non-verbal) picked up
during delivery. Be aware of both positive and
negative feedback and adapt to these signals.
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Reproductive & Child Health Care
Language Choices
There must be instant understanding and impact in oral communication. A listener who asks,
"I wonder, what the speaker meant by that?" has stopped listening. Consider the background
of your audience and the purpose of your speech in making language choices.
Select language that is:
Concrete Be specific - use words that are concrete. Ambiguity is a barrier to effective
communication.
Simple
Adapted
Forceful
Vivid
Concentrate on conveying the message of
your speech in language the audience can
easily understand.
Keep your message
uncluttered.
Words or expressions which have special
meaning to the listener are effective. Avoid
the inappropriate
use of over-tech nical
language, or adapt specialised working
through translation.
State your point In precise, hard-hi tting
words. Stimulate the listener through
dynamic expression. Leave no doubts as to
exactly what you mean or feel.
Vivid language helps to stir listeners'
imagination and activates their senses
through descriptions.
Avoid overused
expressions and common place wording.
Content clarification
Your speech should be instantaneously clear! You can help achieve this goal by including
some of the following techniques of content clarification:
Preview and mini summary
Road signs
Repetition and restatement
Examples: real and hypothetical
This is both a preview and review technique
of content clarification. This helps the listener
see where you have been and where you are.
Prepare the audience for what IS coming
("watch out for this next step; it is difficult"
Repetition of same expressions gives listener
a second chance to comprehend ("let me
repeat that"). Restatement is a form of
repetition with a variety 'of wording.
An example explains and supports a speech
point through the use of a specific instance
or illustration. The real example is based on
facts. The hypothetical example is created
from the imagination of the speaker.
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Information Education & Communication
A speaker must always be positive that there
is no alternative meaning of thoughts or
language used. Nearly all abstract words and
unfamiliar terms should be defined. some
ways of defining are: negotiation - tell what it
is not; classification - tell what group it
belongs to; synonym or analogy-tell what it is
like figuratively.
Use comparisons to show similarities between
known and unknown. Use contrast to show
the differences.
Highlighting and audience involvement
• Highlight
Improve your communication and show listener concern through highlighting. Direct
the listener's attention to key concepts; some methods of highlighting are:
Vocal
Purposeful
Repetition
Variation in volume, tempo, pitch and pause make
certain key ideas stand out.
Use movement and gestures for emphasis. use your
face, body, hands, and physical distance to emphasise
points.
Research tells us that audience remember
restatement ideas that are repeated at least three
times.("Let me repeat that"). Do not be afraid to repeat.
The real control of the speech situation rests with the listener. To keep your audience
"plugged in"
Make use of the rhetorical question.
Keep their interest by varying your speaking style. Use:
=> Vocal emphasis
=> Silence
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Reproductive & Child Health Care
It is not only what is said, it is also the way it is said
~ The voice
Let us sum Up
Information, Education and Communication is a tool which has been extensively used for
advocacy. IEC covers activities such as population education, youth activities, family life
education, contraceptive formation and awareness about the small family norm. NGOs can
play an important role in disseminating information relating to gender equity, equality, and the
empowerment of women, education of girls, adolescent reproductive health and male
responsibility for reproductive health. IEC messages have to be specially tailored through
local talent to be meaningful. It is here that expertise in micro level planning become crucial
for programme impact. Communication method like village dramas on girls' education and
adolescent clubs for correct information about reproductive health can be organised by NGOs
as a supportive intervention to the larger programme.
A coordinated strategic approach to information, education and communication should be
adopted in order to maximise the impact of various information, education and communication
activities, both modem and traditional, which may be undertaken on several fronts by various
actors and with diverse audiences.
Information, education and communication activities should rely on up-to-date research findings
to determine information needs and the most effecti ve culturally acceptable ways of reaching
intended audiences. To that end, professionals experienced in the traditional and non-traditional
media should be enlisted. The participants of the intended audience in the design,
implementation, and monitoring of information, education and communication activities should
be ensured so as to enhance the relevance and impact of those activities.
Interpersonal communication skills- in particular, motivational, and counselling skills- of public,
private, and non-governmental organisations, service providers, community leaders, teachers,
peer groups and other should be strengthened, whenever possible, to enhance interaction and
quality assurance in the delivery of reproductive health, including family planning and sexual
health services. Such communication should be free from coercion.
Governments, non-governmental organisations and the private sector should make greater and
more effecti ve use of the entertainment media, including radio and television soap operas and
drama, folk theater and other traditional media to encourage public discussion of important but
sometimes sensitive topics related to the implementation of the present Programme of Action.
When entertainment media- especially dramas- are used for advocacy purposes or to promote
particular lifestyles, the public should be informed, and in each case the identity of sponsors
should be indicated in an appropriate manner .
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Information Education & Communication
Age-appropriate education, especially for adolescents, about the issues considered in the present
programme of action should begin in the home and community and continue through all levels
and channels of formal and non-formal education, taking into account the rights and
responsibilities of parents and the needs of adolescents. Where such education already exists,
curricula and educational materials should be reviewed, updated and broadened with a view to
ensuring adequate coverage of important population-related issues and to counteract myths
and misconceptions about them. Where no such education exists, appropriate curricula and
materials should be developed. To ensure acceptance by, and effectiveness and usefulness to
the community, education projects should be based on the findings of socio-cultural studies,
and should involve the active participation of parents and families, women, youth, the elderly
and community leaders.
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Questions
• What are the main components of Communication?
• What is the importance of leaning about one's body language to understand a
person better?
• What are things speaker should keep in mind while imparting Sex-Education?
• Clarify - "It is not only what is said, it is also the way it is said"?
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PROJECT FORMULATION
r;r Learning objectives
• Design a project proposal
• Formulate a project budget.
~ Teaching Aids
• Flip charts
• Black board
• Writing material
• Sketch pens.
Project Formulation
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Introduction
The health and related needs of a community are large and diverse. Voluntary agencies/NGOs,
working at the micro level, have a very good understanding of the peoples' problems, working
selflessly and sincerely for the uplift of the underprivileged. However, most of these agencies
are not well acquainted and equipped with the required information, resources, technical
expertise, etc. Optimal management ofthe limited resources (Man, Machine, Material, Money)
is a must for them. They should be able to develop project proposals, within their own priorities
of interest, and know how to mobilise resources and system supports, how to develop indicators
to monitor and evaluate the progress and performance from time to time. This module gives
some guidelines on how to develop a project proposal. A good project proposal is a must to
secure necessary support from potential donors and also serves as a guideline for easier and
effective implementation of the project, as it not only describes the activities to be undertaken,
but also the time frame, monitoring indicators, linkages and financial details.
Writing a Project Proposal
The real basis for any programme is the Project Proposal. The programmes, or intended sets
of activities, and why they are undertaken, are approved as per details furnished through the
proposaL A project proposal should reflect the needs of the community. Hence, any
inconsistency, limitation or inaccuracy in the project proposal may have a misleading effect on
the programme.
A project proposal indicates what is proposed to be done towards achieving what aim, the way
it is to be done and the consequences it would lead to. It is an information document for the
funding agency and a guide for the implementing agency. It should have an inbuilt system of
implementation, monitoring and evaluation. It contains factual information in a logical
framework including implementation process at all stages. It should be self explanatory so that
anybody reading it would understand the basis of the programme and the programme itself. It
should not have any ambiguity. Sometimes, funding agencies develop their own guidelines to
suit their objectives. Guidelines are only a rough structure to arrange the information in
sequential flow.
1. Title
2. Executive Summary
3. Background of the Implementing Agency
4. Rationale
5. Objectives of the Project
6. Methodology
7. Monitoring and Evaluation
8. Sustainability
9. Budget .
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Project Formulation
The title should communicate the nature and area of the project. It should not be
misleading or meaningless.
• Executive Summary
The Executive Summary gives the gist of the project proposal, i.e., in short, it mentions
why this project is necessary and how it will be done.
• Background of the Implementing Agency
Give all relevant information, supported with enclosures, about your organisation.
Explain why and how the organisation was formed, its mission, thrust areas, availability
of resources (human, financial and infrastructural), previous programmes implemented
by the organisation (including amount of funds handled and the respective funding
agencies) and linkages with other NGOs/Govt. Departments/industrial houses, etc.
It is essential to project the true picture of the organisation, but avoid writing too much
about the organisation. It should be specific, clearly spelt out and condensed. Some of
the possible information heads are given below:
The name of the organisation would be mentioned on the face sheet(cover).
However, the acronym of the organisation, if any, should also be written.
Explain why and how the organisation was formed. State the vision and mission
of the organisation clearly. Clarify the nature of the organisation, i.e. whether
religious, political, charity, developmental, welfare, commercial, etc. It is better
to enclose a leafletlbrochure of the organisation for ready reference.
• Structure - Mention about the membership pattern, types of members, whether
it has a general body or executive body.
• Developmental stages - Explain how the organisation initiated activities and
all the steps undertaken ~nd the stages of its development. It should include the
geographical and technical expansion, stating the number of userslbeneficiaries,
villages and activities.
• Thrust Areas - It reflects the values and ideology of the organisation, what the
organisation prefers to do, what are its areas of operation stating the priorities
of involvement. For example, one organisation may take non- formal education
as its thrust area, another might take health, and a third income generation.
Thrust area includes two things -
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Reproductive & Child Health Care
(i) The nature of activities the organisation prefers to do depending upon its
expertise and infrastructure
(ii) The identified need of the community may be the thrust
(c) Legal Status
• Registration No. - Write the registration number of the organisation stating the
nature of the organisation, i.e. whether society, trust or company, etc, along
with date of registration. Write the date of renewal also, if any, and enclose
photocopies of the registration number and Memorandum of Association.
• FCRA No. - Write the FCRA number of the organi&ation along with date. If it
is a one-time permission, the same should be clearly mentioned including the
duration/time limit. Enclose copies ofthe FCRA number and the latest Balance
Sheet in order to confirm the continuity of the FCRA No.
• Any other registration - Write the name and date of other registrations like
SOG, 12A, KVIC, etc and enclose photocopies of the same.
(d) Bank information
• Banker - Write the name and full address of the bank where your organisation
is operating an account. Maintain separate accounts for Indian funds and foreign
funds.
• Account No. - Write type of account, whether Savings or Current and Account
No. of your organisation as per FCRA registration.
Write a few words about the strategy of your organisation vis-a-vis project
implementation at all stages. How do you select an area, identify the needs of the
area, formulate the project proposal, implement the project, raise and manage
resources, develop linkages with support agencies, monitor the progress, review
and evaluate the project and phase out from the area.
if) Resources
Indicate the availability of resources with the organisation to show its capability.
They may be-
(i) Human resources
(ii) Financial resources
(iii) lnfrastructural resources.
(i) Human Resources - Give the number, level, expertise and experience of
your staff members who would be responsible for the envisaged
programme. The duration of their involvement in developmental!
organizational activities should be highlighted .
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Project Formulation
(ii) Financial Resources· Write about the financial resources available with
your organisation. The organisation might have a corpus fund, or a regular
income from service charges or rent or consultancy or subscriptions, etc.
(iii) Infrastructure Resources· State the infrastructure available with your
organisation which can be useful for project implementation. It may be
building, office, vehicles, furniture, equipment, etc. It indirectly reduces
the cost of programme implementation and indicates the possibility of
further expansion of the project activities. Infrastructure also confirms
the stability of the organisation and possibility of easy and early
implementation of the project.
(g) Previous Programmes
Programmes increase credibility of the organisation with the community and the
donor agencies. You should mention the programmes and projects implemented
by your organisation so far and those currently being handled, indicating the funding
agencies, components of the project, nature of experience, duration of the project,
area covered, etc., total funds received for each project and funds raised from the
community, if any.
A copy of the latest annual report may be enclosed to convey more information on
the activities undertaken during the previous year.
• Rationale or Purpose
The rationale gives the justification or need of having the proposed programme. The
holistic picture of the community to be served should be projected. In a service delivery
or awareness generation programme, the following sub-headings may be used-
=> Geographical Location ( map to be enclosed)
=> Population (including demographic features)
=> Literacy Level
=> Health Status
Under rationale, clearly state what are the potentials available in the community, how
the programme will tap and develop them. The information on beneficiaries, particularly
women, is required to form a solid basis for the programme.
Also, mention the availability of local groups, availability of manpower, willingness
of the people to cooperate, output and impact envisaged, the magnitude of the problem
and the absence of similar programmes for the community.
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• Objectives of the Programme
The objectives provide direction to the project activities. It is what you want to achieve
within a stipulated time period. The objectives should have the following characteristics:-
~ They should be measurable, which can be analysed and explained in well-defined
measurable units
~ They should be practical and not idealistic, keeping in view the capacity of your
organisation and the project area
~ Some writers state objectives in the abbreviation SMART - Specific, Measurable,
Achievable, RelevantlRealistic, Time bound
Objectives can be further divided into "long-term objectives" (or Goal or Main
Objectives) and short term objectives (or Working Objectives or Specific Objectives).
The long term objectives are parts of the vision that you want to actually see in the
community after a fairly long time, like improved quality of life, poverty alleviation,
etc. They are general in nature indicating the long-term impact of the programme. The
short term objectives are the immediate results envisaged in the programme.
The methodology gives details of the implementation strategy of the project. Keeping
each objective in mind, a set of activities are designated to realise each objective.
Indicators are identified to measure the result of the activities. Each activity should be
given a definite time frame.
Write the activities of the project in a logical sequence, having relation directly or
indirectly with the stated objectives. The objectives are the condensed summary of
expected results while the activities are the condensed summary of efforts leading to
achieve the stated results.
Indicators reveal the result of the activities. One objective may have more than one
indicator. They provide the basis for monitoring and should have not only quantitative
units, but qualitative units also.
The strategy/methodology mentions in detail how the activities will be introduced to
the community.
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Project Formulation
Chronogram - This is an implementation schedule (work plan) of the project activities
with reference to time limits. A chronogram is important for doers and managers both,
as it specifies the progress of activities. Write all the activities of all the components
preferably in the order of implementation and shade/tick the column of time. Through
a chronogram, one can easily analyse the activities against the planning.
- Example Project on Training of NGO Workers
, Activities
Implementation Schedule
Month
1-4 5-8
9-12 13 -16 17 - 20 21 - 24 25-28
29-30
1. Development of E
)
training material
2 Identification of
Vo1ags &
E
)
participants
3 Training
Workshop
4 Mid-term
Evaluation
,
~
5 Refresher
Training
6 Monitoring
i
7 Upgrading
Training Materia
(
)
8 Final Evaluation
& submission
of report
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Reproductive & Child Health Care
• Monitoring & Evaluation
Monitoring is the mechanism of reviewing the progress of the efforts to achieve the
objectives within the prescribed time limit. A project may be monitored by the staff of
the organisation, or by local groups, or by the beneficiaries themselves. It may be
monitored by several or all of these groups. The monitoring system should have a
feedback mechanism. The flow of information and the feedback system should be
clearly defined. A well structured monitoring system, having a systematic management
information system, increases the possibility of success of the project.
Evaluation is the process by which the impact of the programme is analysed from all
angles, i.e. planning process, participation, accounting, attitudinal changes, behaviobral
changes, etc.
The funding agencies desire that their projects become permanent features of the
community. The proposal should clearly explain the level of sustainability the project
would attain, depending on the nature and objective of the project.
• Budget
Project finance is the life of the project. Manpower, material and machines are arranged
mainly on the availability of resources (money).
The total financial requirement for the project is written under the budget head. It
should be calculated keeping every bit of expenditure in mind. All the components
should be broken into smallest possible segments. The budget should be written
separately for each component. The components can be grouped under two broad
heads - non-recurring and recurring. The cost estimates for each activity should be
justified logically .
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Project Formulation
Example - Budget for a Training Project
Non-Recurring Items
• Development of
Training Material
• Overhead projector
(OHP)
• Slide Projector
Sub-Total
Recurring Items
• Salaries
=> Project Coordinator
=> Project Associate
=> Secretary
• Training Cost (cost
of 1 Workshop x No.
of Workshops per year)
• Postage &
Communication
• Office Expenses
• Stationery
• Repair &
maintenance
• Contingencies
Sub-total
Grand Total
Year 1 Year 2 Year 3 Total
A
-
-
-
Bl
B2
B3
A+BI
B2
B3
B4
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Questions
• Design project proposals (including budget) on the following issues
1. Identification and treatment of RTIs in the community.
2. Increasing contraceptive prevalence in the community.
3. Changing social attitude for better health status and economic
standards.
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I I ANNEXURE
Project Formulation
A SAMPLE PROJECT PROPOSAL
2. Executive Summary
The project envisages to cover a population of about 50,000 in 10 selected 11 clusters in
the PQR slum areas of Delhi. The main strategy of the project would be to undertake a
door-to-door survey of all the eligible couples in the area, collect relevant information
from them, identify and treat RTI (Reproductive Tract Infection) cases and further motivate
and counsel them into accepting a family planning method.
3. Background
ABC is a non-political, non-sectarian, non-profit making NGO working in the field of
Maternal and Child Health and Family Planning for the last 15 years. Registered in 1983,
under the Societies Registration Act, ABC has its head office in New Delhi while it has
been working in different States such as Haryana, Uttar Pradesh, Delhi and Himachal
Pradesh through its project offices. ABC is engaged in providing health care services to
the urban 11-population in Delhi. The organization is also registered under the Foreign
Contribution Regulation Act (FCRA).
The broad objectives of the organization are :
• to help the underpriviledged and the needy to help themselves
• to provide for a participatory process of development
• to conduct research and evaluation studies on health, nutrition and education
• to organise training, education and rehabilitation programmes
The following documents are being attached along with-
• Organisation brochure
• Memorandum of Association and Rules and Regulations
• Certificate of Registration
• Certificate of 80-G
• Annual Report
• A gist of important earlier activities
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4. Rationale
The dimensions of population growth in developing countries, especially in India, poses a
great challenge today and all efforts towards development are neutralized by the ever-
growing population, thus making the net impact negligible. Therefore, this unplanned
population growth has to be tackled not only by the Government but also by grassroot
level NGOs. ABC is complementing / supplementing the Government efforts in contributing
towards increasing the CPR, by advocating the use of spacing methods in addition to
addressing other reproductive health and development issues.
The project will be implemented in the PQR slums and adjoining JJ-clusters. It is a hilly
and rocky area full of dust and dirt which earlier used to be surrounded by stone quarries.
The main occupation of the JJ-cluster inhabitants is casual labour, stone crushing,
transportation, factory work, etc.
The area is large, inhabited predominantly by migrant workers from various states of the
country. There are some 21 JJ-clusters in all spread over an area of 10-15 km. The total
population of the target area, covering 10 JJ-clusters, is around 50,000.
Since the area is largely inhabited by casual labourers, the socio-economic conditions are
appalling. The area lacks basic amenities such as sewage, drainage and general sanitation.
Defecation is done in the surrounding open fields. Further, as a result of stone crushing
activities, several pits of varying sizes have come into existence which get filled with
water, particularly during the monsoons. This facilitates mosquito breeding. Prevalence
of various communicable diseases like tuberculosis, skin diseases (scabies), eye disorders
are reported to be very high. Prevalence of malaria is also quite high. The nutritional
status and awareness in general is very poor and children with marasmus and kwashiorkor
are commonly seen.
There are some doctors, trained and untrained, who cater to the medical needs of the
people, along with an ABC static clinic where outpatient services are being provided. But
these services are not enough to accommodate such a large crowd of people.
ABC proposes to cater to the Reproductive Health needs of women living in the area, by
providing the much needed antenatal care (ANC) and postnatal care (PNC) services,
ensuring safe deliveries, identifying and treating RT.Is and also making safe abortions
available in the area. All family planning spacing methods would be made available at the
ABC static clinic. Couples would be counselled, Whenever needed, to accept a
contraceptive method. Immunization of children, growth monitoring and nutritional advice
would also be provided. The project aims to reach all the families living in the area, by
providing basic health needs, in general, and addressing the reproductive health needs of
couples, in particular .
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Project Formulation
5. Objectives
• Main Objective
To strengthen and/or initiate some selected social and economic factors and processes
for population stabilization by promoting reproductive health services, income
generation activities and participatory processes of education and mobilization of
women. The focus would be on regulating fertility, promoting family planning
acceptance and encouraging the use of modern health care facilities included in the
reproductive child health concept.
~ To provide comprehensive preventive, promotive and curative health services
leading to safe motherhood
~ To provide counselling on safe sex and sexual health related problems
~ To create awareness about RTls/STDs, and identify and treat these cases through
the WHO modified syndromic approach
~ To create awareness about mv/AIDS, its prevention and management, and provide
counselling to patients and their families
~ To provide family life education to adolescents
~ To set up 10 counselling centres
~ To upgrade income generating skills of women.
6. Methodology
The project will focus on the following components and target groups :-
(a) Eligible Couples - All couples having undergone sterilization would be identified
and examined for health problems. They would be treated for nutritional anaemia,
RTls and other conditions.
(b) Pregnant Women - All pregnant women would be given ante-natal check-ups,
including tetanus toxoid injection and safe delivery packs. High risk cases would be
identified and referred for specialist treatment.
(c) Post Natal Mothers - Post natal check-ups would be provided. Breast feeding would
be encouraged and immunization carried out. Awareness programmes on nutrition,
weaning and child development would also be conducted.
(d) RTI Cases - Cases would be screened by the paramedical staff and referred to the
Project Doctor (Medical Officer) for treatment. Laboratory investigations, wherever
needed, would be provided. All cases of RTls would be provided with the necessary
medicines, including antibiotics.
(e) Adolescents - Adolescents, especially school dropouts would be given family life education.
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Reproductive & Child Health Care
(f) Mahila Mandals • Mahila Mandals would be organized in each cluster to create
awareness on issues related to health and nutrition, immunization, hygiene and
sanitation and family planning. Skill development for income generating activities
would also be done through Mahila Mandals.
The implementation strategy for providing stipulated services would be through a static clinic
and counselling centres, by social workers, Auxilliary Nurse-Midwife, RCH Counsellor and a
mobile IEC team. The static clinic will also be the project office. It is proposed to set up 10
counselling centres, one in each 11 cluster, to provide the following:-
• Counselling to young men and women on reproductive health matters, including safe
sex, by advocating the use of condoms
• Screening of RTI cases / STD cases (Potential) and their referral
• Creating awareness about HIV/AIDS, their prevention and also management of
such cases
• Creating awareness amongst adolescents on sexual health issues
• Training in making sanitary napkins, children's garments, petticoats and detergents,
etc, as income generation activities.
The proposed project will have the following personnel and each of them will be entrusted
with specific responsibilities as has been outlined in the following table :-
Personnel
Project Manager
Medical Officer (MO)
ANM
Social workers
No.
1
I
1
10
Responsibilities
Overseeing
the project
activities, liaising with the
Government functionaries,
monitoring and reporting
Providing
services,
counselling,
necessary
all medical
including
as and when
Helping the MO and
providing
immunization
and counselling services
Assisting
the
Project
Manager, MO & ANM In
project activities, field visits,
counselling,
conducting
IEe camps,
assisting
referrals, assisting Income
Generation activities
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Project Formulation
Each social worker will organize a Mahila MandaI in a JJ-cluster and the IEC team headed by
the Project Manager will operate from a volunteered accommodation in the area. Each cluster
will be visited biweekly. The doctor will look after the therapeutic and curative needs of the
target people with the help of the ANM, whereas the Project Manager will arrange IEC camps
with the help of the social workers. However, the Project Manager may need some IEC training
in FW IMCH which will be imparted at the ABC head office. The IEC material will be procured
from the MOHFW/ Funding Agency and some will be suitably modified.
Complicated cases will be referred to the ABC static clinic which would be located in one of
the JJ-clusters and manned by the Medical Officer. ABC will contribute free office space for
the project staff in the area, along with other logistic support.
The overall management/day to day reporting of the activities will be done by the MO and
Project Manager and sent to the head office for documentation and record.
Initially, a one month training will be imparted by the organisation, at their head office. For
imparting training to these workers, ABC will be drawing from their regular resource faculty.
As already mentioned, each JJ-cluster would have one Mahila MandaI (MM) and each Mahila
MandaI (MM) shall try to bring under its platform all the newly married women or women
having 2 children, sterilized cases, mother volunteers, ANC/PNC cases along with RTI cases.
Social workers (SW) shall be carrying out growth monitoring of young child (0-3 years) with
the help of other workers like Anganwadi/Mahila Swasthya Sangh and mother volunteers
under the direct supervision of the ANM. SWs will also identify malnourished children to be
referred to the MO at the time of mobile teamlIEC team visits or to the ABC static clinic.
Certain items such as weighing machines, thermometers, hot water bags, some bandages and
first-aid items may have to be provided at each MM. The venue of the MM will also be
utilised for holding non-formal education classes for adolescent girls (10-14 years), particularly
school drop-outs. These classes will be conducted by SWs/mother volunteers. The issues to
be discussed will also include items like personal hygiene, sanitation, menstrual cycle and
puberty, responsible motherhood, benefits of small family besides teaching them basic arithmetic
required for day to day home management.
At the intermediary level, a mobile IEC team consisting of SW of the area, Project Manager,
MO and ANM shall be visiting the area as per a pre-determined schedule, to carry out educational
and awareness programmes along with curative/diagnostic services, ante-natal / post-natal
check-ups and treatment of RTI cases.
At the macro level, the existing ABC static clinic shall be the centre of multifarious activities.
Space, building and other infrastructure required for running the office shall be contributed
by ABC.
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Activities
• Recruitment & training of staff
• Baseline data collection
• Project Activities
=> Health care services
=> Formation & training of MMS
=> IEC activities
-+ Campaigns/Exhibitions
-+FLE
-+ Orientation
-+ Training on IG activities
I.• Monitoring
Evaluation
Activity Plan
Year 1
Year 2
Year 3
Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4 Q1 Q2 Q3 Q4
.-..
.----.
.-----. .-----. I•••
I""'"
.. ,
...•
••..
L...
...•
••...
"'" ......--. ~
~
~
~
H
..-------.
+-----+
+-----+
•• ~
L..• .
'I ~
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Project Formulation
• Expected Outcomes and Indicators
The project interventions would achieve the following changes, particularly in the
community and target groups -
=> increased awareness about appropriate RCH practices, need for population
stabilization, reduction in maternal and infant mortality rates, safe delivery.
=> greater access and utilization by the target groups on RCH and general health and
welfare services.
=> improved ability of women to take informed decisions with regard to maternal
health, delivery, birth spacing and child care.
=> empowering women through IEC and IG activities.
7. Monitoring & Evaluation
The Project Manager will monitor the project with the help of the rest of the team. The
data based on the community needs will be taken as a guiding factor for monitoring the
ongoing activities. The service coverage data will be maintained at the project office,
which will be recorded and processed for monitoring the project activities. The Project
Director of ABC will be overall responsible for the project.
Quarterly and annual progress reports will be sent to the funding agency for
project evaluation.
8. Sustainability
The project would be carried out keeping it participatory, location specific, community
based and people centred. These essential components would maximise sustainability of
the project after its termination.
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Reproductiv~& Child Health Care
9. Budget
I Non-recurring expenses
• Bicycle (1)
• TV (1)
• VCP (1)
• Lab equipments
• BP apparatus
• Weighing Machine
Total I
II Recurring Expenses
1. Salaries
• Project Manager (1)
• Doctor (1)
• ANM (1)
• SWs (10)
• Lab Technician (1)
(Part-time)
• Pathologist (1) (part-time)
• Typist (1) (Part-time)
2. Baseline Study
3. Staff Training
4. Travel
5. Medicines & Lab Reagents
6. lEe material
7. Training for IG activities
8. Overheads & Misc.
Total II
Total I + II
Year 1 Year 2 Year 3 Total
.
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Project Formulation
Enclosures
Annexure 1 - Demographic Data of the Slum
Annexure 2 - Map of the City highlighting the Slum Areas
Annexure 3 -
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Project Implementation, Monitoring And Evaluation
PROJECT IMPLEMENTATION, MONITORING
AND EVALUATION
c:o= Learning objectives
On completion of this module, all the participants should be able to
• Identify the steps in implementing a project
• Define the concepts of monitoring and evaluation and their use in improving
efficiency and effectiveness in implementing RCH programmes.
• Identify the relevant indicators and feedback mechanisms for monitoring
programmes.
• Design evaluation mechanisms for achieving objectives of health programmes.
~ Teaching Aids
• Flip ch~s
• Histograms and graphs etc.
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Reproductive & Child Health Care
Introduction
Monitoring and evaluation occupy a key place in implementation of any action oriented project.
It is only through effective monitoring that projects can be implemented successfully and can
achieve the desired goals. Simultaneously, a well-planned evaluation exercise may also indicate
the extent to which the project has been successful in fulfilling its targets. Therefore, it becomes
necessary to know, in detail, the concept of project implementation, monitoring and evaluation
in order to carry out project activities in a systematic and scientific manner. This module
describes the various steps required in effectively implementing and monitoring project activities
and also deals with various methods of project evaluation.
Implementation
• Steps in implementing a project
For successful project implementation the following steps must be followed:
=> Listing out the major activities
The first and foremost task is to prepare a list of the major activities that are to be
undertaken to achieve the objectives of the project. Most of these activities may
have already been listed out in the project document (proposal). However, several
other activities, which would facilitate in achieving the stipulated goals of the
project, may be identified when the project actually takes off.
=> Preparation of Activity Plan
After listing out the major activities, it is necessary to draw up a time schedule
with respect to initiation and completion of each of these activities. The activity
plan simply indicates the point in time at which a specified activity would start
alongwith the timeframe during which it is likely to be completed. This time bound
activity plan helps in assessing whether the project is being implemented as per
schedule. In case of delay, it helps in identifying the delayed activity and also the
magnitude of the delay. The activityplan may be developed using the following example:
Activity Plan
Activities
12
• Recruitment of staff
~
• Training of staff members
~
• Initial contact with community ~
• Base line information collection ~
• Service delivery
(
• Evaluation (final)
Months
3 4 5 67 8
9 10 11 12
>
~
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ProjectImplementation,MonitoringAnd Evaluation
The activity plan discussed above, takes into consideration the major activities of
the project. It is also necessary to draw up finer details of each of these activities.
For example if a major activity is to undertake training of volunteers on reproducti ve
health issues, the finer details under this major activity may be identified as:
-+ number of volunteers to be trained
-+ date, duration and venue of training
-+ identification of resource persons for training
-+ materials required for training
-+ arrangements of lodging and boarding
-+ logistic support required in conducting training sessions (eg. audio-visual
aids, black board etc.)
The successful implementation of any major activity of a project depends on the extent to
which these minor details have been worked out and planned for.
• Infrastructure and Logistics
Another very important aspect in project implementation is identifying the tools and
equipments required that would facilitate the project work. The implementing agency
should have the required infrastructural facility and logistic support to carry out the
project activities. Before implementation, it becomes necessary to review the existing
infrastructural facilities and identify those needed in future, for smooth running of the
project. If the project requires providing curative services in the project area, one must
review whether these services can be rendered with the existing infrastructure. If
not, the additional facilities must be listed out and acquired from within the
sanctioned budget.
Proper planning is also needed to ensure continuous supply of logistics. For example
in case of distribution of contraceptives, it is essential to ensure steady supply of
contraceptives.
An assessment of the required manpower to carry out the project activities is essential.
Depending upon the nature of activities to be carried out, the area to be covered etc.,
the number of project personnel required at different levels should be clearly worked
out. The work load or capacity of the worker at various levels may be worked out
as under:
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Reproductive & Child Health Care
After getting an idea of total number of mandays of work, the staff requirement can be
easily estimated while taking into account the time available to carry out the
project activities.
In any action research project, the project activities are carried out through grass-root
level workers and other supporting staff at various levels. The successful implementation
of any project depends upon the coordination between the various workers. Therefore,
it is essential that the kind of field work to be carried out by each level of project
personnel is well planned and responsibilities are earmarked clearly. This not only
helps in boosting the project activities but also makes each worker aware about his/her
responsibilities, in turn making coordination simpler.
Proper manpower planning also helps in identifying the exact number of personnel
required for the project. The recruitment of project staff must be done on the basis of
responsibilities and work load assigned to each worker. For each worker the job
descriptions should clearly be identified. The project manager has to justify the
recruitment of staff and accordingly, the positions may be filled up.
After recruiting the project personnel, it is also important to assess their capabilities
and expertise in carrying out the project activities. If required, the project manager
may plan for manpower development training to improve certain skills as demanded in
the project. A training cum orientation programme may be organised for the new
recruits to facilitate them to perform better.
• Supervision and Guidance
Successful implementation of a project involves continuous supervision of the activities
carried out by the supporting staff. An effective mechanism of supervision should also
be worked out in advance. The tasks to be carried out by a worker should be clearly
defined. An effective management information system (MIS) has to be evolved whereby
the proper flow of information from below upwards and effective supervision from
above downwards is developed. The project manager should not only supervise his/
her immediate subordinate staff, but also keep an eye on the other workers.
Along with supervision, proper guidance is also required. In fact, supervision does not
mean "fault-finding", but rather, guiding the project personnel to work better. Regular
supervision and guidance helps in assessing the progress of work and rectifing mistakes.
Implementation of action oriented projects requires regular field visits by supervisors,
and occasionally even by the top level management. These field visits help in both
supervising the progress of work and in boosting the morale of the grassroot workers.
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ProjectImplementation,MonitoringAnd Evaluation
Field visits by senior staff should be made not to pick on mistakes committed by the
workers, but to help, facilitate and encourage them to work more effectively and produce
the desired results.
An important component of successful implementation of any project includes holding
staff meetings at regular intervals. The periodicity may differ from project to project,
but these regular meetings help in addressing problem areas and issues. Staff meetings
also provide an opportunity to assess the progress of work. Achievements made so
far, and future plans of action may also be discussed during these meetings. Such
meetings also help in keeping the grass-root workers in tune with the objectives of the
project. It is only through these meetings that various problems can be identified and
steps can be initiated to overcome them. In a way periodic staff meeting is also a way
of supervising project staff.
A rough estimate should be made of each segment of the target population such as
infants, pregnant women, lactating mothers, eligible couples, adolescents, men and
women suffering from RTls/STDs in the project areas. For example if the project aim
is to provide full coverage of children's immunization, an approximation about the
number of infants in the project area should be made. The number of infants would
depend upon the birth rate prevailing in the project area or it can be borrowed from the
experiences of another population having similar characteristics as in the project area.
If the crude birth rate of the project area is around 30 births per thousand population, a
rough idea of the number of infants can be derived by the same. It means 30 births
occur, on an average, per thousand population living in the area in a year, and the total
number of infants would be estimated by applying this figure to the total population
of the area.
Similarly it is found that given the marital pattern of our country, eligible couples
constitute nearly 16-17 percent of the total population. An estimate of the number of
eligible couples may be derived by applying this percentage to the total population of
the project area. Regarding the number of men and women suffering from RTls or
STDs, this can be generated from field enquiry by grass root workers, visiting house
to house as a part of their motivational activities.
The purpose of action research projects is to provide certain services to the community.
Hence it becomes very important to seek the support of the community for successful
implementation of any project. This may be secured by involving community leaders,
beneficiary groups and common people for propagating the facilities available in
the project.
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Reproductive & Child Health Care
Monitoring
Monitoring can be defined as a process of measuring, recording, collecting and analysing data
on actual implementation of the programme and communicating it to programme managers so
that any deviation from the planned operations are detected, diagnosed and suitable corrective
actions taken. Monitoring is an extended form of supervision, which is a day to day inspection
of the work done.
The purpose of monitoring is to ensure that the programmes are implemented as planned.
Therefore, for any monitoring system to be effective, a plan for the main programme needs to
be prepared carefully. Such a plan would specify what needs to be done, who is responsible
for it and when it is to be done. Inadequacies in planning directly contribute to inadequacies in
monitoring. Hence,
• The plans should identify key result areas and define how they will be measured. They
should identify linkages between inputs and outputs, if necessary, through intermediate
indicators.
• The plans should prioritise activities so that they receive adequate emphasis during
monitoring.
• The plans should cater to local variations. Otherwise monitoring would identify programme
performance and variations which do not require any action.
The monitoring process consists of:
• detecting deviations from plans
• diagnosing causes for deviations
• taking corrective action
Detection is the first step in monitoring and is carried out by comparing plans with actuals in
terms of programme inputs, activities and outputs. The question here is, "what should be
measured and how much deviation should be tolerated without further investigation."
Reasonable tolerance levels for performance deviation should be set.
Once the areas of shortfall have been detected, the causes for these deviations need to be
identified, followed by taking up correcti ve actions, if necessary.
The following measures, if undertaken systematically, may lessen the chances of deviations
between project inputs and outputs:
• use of participation in the planning process to obtain staff commitment for
implementation
• use of experts for advice
• staff training to reinforce skills and commitment
• strengthening of supervisory systems
• giving feedback of suitable information
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Project Implementation, Monitoring And Evaluation
For successful implementation of any project, monitoring should be done systematically. Later,
in this section of the module, we shall describe in detail the steps involved in
systematic monitoring.
A primary task ofprograrnme managers is to try to ensure that within a given time period, the
planned targets and objectives of the programme are achieved. But the effectiveness of
monitoring will depend on the precision with which targets and objectives are defined, on their
validity and on whether they can be quantified. Vague objectives should be avoided while
designing projects.
Indicators have been described as "variables which help to measure changes". Ideally,
indicators should be:
• Objective - the answer should be the same when measured by different people in similar
circumstances
• Social and economic indicators related to health
=> rate of population increase
=> income distribution
=> adult literacy rate
=> food availability
=> increase or decrease in industrialisation
=> climatic variations affecting agricultural output if project covers a time span of I
year or more
• Indicators of the provision of health care
=> coverage of immunization among children
=> coverage of ANCIPNC and natal services
• Health status indicators
=> nutritional status of children (birth weight/growth monitoring, etc.)
=> infant mortality rates
=> crude death rate/life expectancy at birth
=> maternal mortality rate
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Reproductive & Child Health Care
• Evolving a system of Record Keeping
The first step in monitoring is to evolve a system by which proper records may be
maintained. The system of maintaining records should be developed in a manner that
facilitates meaningful analysis of the data available. It is also important to format these
records in a manner by which retrieval is easy.
Records may be of two types:
=> Records on documentation of the activities of the project. (eg. number of training
sessions conducted, number of participants in each session, basic background
information of each of the participants, number of times health camps were held,
to whom these services were given, etc.)
=> Records that come from the project area or from the population residing in the
project area. (eg. general characteristics of the population, basic characteristics
either of the households or of the beneficiaries, number of children below age I,
various types of immunization provided to these children below age I, number of
pregnant women and those who are provided with ANC, etc).
It is the second type of information by which an impact on a population can be measured.
While evolving a system of record keeping, it must be emphasised that the system of inflow of
the information, its retrieval, compilation and analysis may be carried out without much
difficulty.
Information gathering and reporting should be done in a structured manner. Record keeping
should be such that retrieval of records is easy. The use of computers for data entry, analysis
and updating of records proves very useful for larger, long-term projects.
The purpose of monitoring any action research project is to evaluate its impact on the
community. For this, a base information is required against which the achievement
gained can be measured. The baseline data usually pertains to the time period when the
project started. These data reflect the field conditions at the beginning of the project
and any change brought about later may be claimed to have been achieved due to
project activities. As will be discussed later in this module, the information collected
during the initial period is helpful during the mid term and final evaluations of
the project.
• Information Consistency checks
Proper monitoring also implies that the information and records compiled from the
project area are correct. For this reason, it is required to conduct a few consistency
checks on the data collected from the field. For example, if the in(ormation received
pertains to the project activities, one needs to cross-check whether the reported activity
had been undertaken at the time, place and venue reported. The validity of the data
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Project Implementation, Monitoring And Evaluation
should be ascertained. It should be kept in mind that the data that is collected is accurate,
timely and easy to understand. The word "FACTS" helps in describing the essentials
of any data-
F- Factual
A- Accurate
C- Concise
T- Timely
S- Simple
For the purpose of consistency checks, the project manager has to make field visits. Such field
visits can often be clubbed with the regular supervisory visits .
• Monitoring Indicators
In any RCH project, the system of record keeping should be such that the basic indicators
for monitoring are included. The purpose of RCH projects is to improve the maternal
and child health conditions in the project area and to enhance family welfare at the
household level. For this, a number of indicators may be listed:
~ Coverage of ante-natal care
~ Coverage of deliveries conducted by trained personnel
~ Prevalence of nutritional disorders of women and children particularly of pregnant
women and lactating mothers.
~ Immunisation coverage of children
~ Prevalence of childhood diseases
~ Prevalence of STDs, RTIs
~ Health seeking behaviour of the population
~ Use of contraception by eligible couples and the methods adopted
~ Levels of fertility and child mortality in the project area.
For each of the above indicators, certain indices may be computed. For example, to represent
the coverage of ANC, one can collect information from each pregnant woman: whether she
has undergone antenatal examination by a doctor or an ANM (minimum 3) and the details
regarding IT injections, IFA tablet ••, B.P. checkups and urine examination. Based on the number
of women receiving this care and the total number of pregnant women in the area, one can
compute the percentage of pregnancies receiving ANC care.
The base line data required to identify the above indicators has to be collected through a sample
survey. Later, regular field visits may be conducted to collect this data to check the progress
of work.
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Reproductive & Child Health Care
• Presentation of Monitoring Report
As a part of regular monitoring, the information must be presented in a summary form.
A report can be prepared based on the information collected for a specified interval of
time. For example, all the activities carried out during one quarter of the year may be
summarised and the vital events occurring in the project population may be reported.
This is called a quarterly progress/monitoring report. The purpose of such presentation
is to analyse the events as and when they are occurring. This would also help in the
process evaluation of the project.
In the same manner as we secure community involvement at the beginning of the
project, we should ensure that monitoring also involves people's participation. The
project personnel may evolve a system by which a continuous feedback should come
from the community regarding the direction in which project activities are moving.
Evaluation
Evaluation is a continuing managerial process aimed at correcting and improving actions in
order to render the activities more relevant and effective. This involves a critical analysis of
different aspect..'iof implementation of a programme, its relevance, its formulation, its efficiency
and effectiveness, its costs and its acceptance by the community. An evaluation should not
only identify problems, but should also provide a basis for recommending actions to solve
these problems. While evaluation is a continuing process, its results have to be summarised
and reported at given times or specified intervals. Often, health programmes require longar
period for its impact to be felt. Therefore, while the assessment of progress and efficiency
may be carried out annually, to see the process aspect, a longer time span would be req uired in
the assessment of effectiveness and impact.
The process of evaluation consists of the following steps:
• specify the particular subject for evaluation
• ensure information support
• verify relevance
• assess adequacy
• review progress
• assess efficiency
• assess effectiveness
• assess impact
The above processes should be used in a flexible manner and should be adapted to the
circumstances in which it is to be used. Before starting an evaluation, the following need to
be decided:
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Project Implementation, Monitoring And Evaluation
• At what organisationallevel/levels is the evaluation to be made?
• What is the purpose of the evaluation? Is it to assess impact or for any other purpose?
• What are the constraints that could limit the utility of the evaluation or restrict
its scope?
• What types of decisions may be taken in the light of the evaluation results?
• To whom are these results going to be communicated?
Evaluation of a project is generally done at two points: mid-term evaluation and end line or
final evaluation. Evaluation of the project methodology may be either Quantitative and
Qualitative or both.
This module briefly describes various types of evaluation and its methodology.
Mid term evaluations, as the name suggests, are carried out during the middle of project
implementation. The purpose of such mid term evaluation is to assess the direction in
which the project is moving so that corrective measures may be taken, if necessary.
End line evaluation is carried out towards the end of the project implementation period
or after the completion of all the project activities. The purpose here is to assess the
effect and impact which the project activities have made together with recommendations
for future replicability and experience sharing.
• Methodologies for Evaluation
The methodologies for evaluation depend on the purpose of evaluation and the policy/
programme/services/institutions under consideration. As mentioned earlier, evaluation
can be conducted either utilising quantitative tools or qualitative methods. The choice
of methodology varies from project to project and depends on the constraints of
resources.
The following strategies are often used for data collection:
=> Review of records - these include those maintained by the health system, including
vital events, registers etc.
=> Case Studies - these can be used to collect information to measure satisfaction!
non-use of services.
=> Controlled experiments - in this, 2 similar areas are selected and baseline data on
relevant health indicators is collected. In the experimental area, the project
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Reproductive & Child Health Care
interventions are implemented. In the control area, no interventions are initiated
and care is taken to see that the situation is not disturbed. At the end of a suitable
time interval, data on relevant health indicators is again collected in both areas.
The difference in changes in health indicators is used to assess the impact of the
intervention.
~ Sample Surveys - these are designed specifically for the household and health care
provider levels. These surveys often provide quick results and prompt feedback at
low expense. However, they have to be carefully designed and should concentrate
on a selected number of indicators.
We shall now discuss sample surveys in detail, as it is the most common methodology adopted
to evaluate health projects.
-+ Survey design
The survey design should include collection of information from the household
level, community health personnel, community leaders etc. Household surveys
should be organised for units of population that correspond to operational or
administrative levels at which the programme managers need information for
decision making.
-+ Sampling design
A frequently used definition of a household is a group of people living together
who share food from the same kitchen. Households should be selected by
simple random sampling, systematic sampling procedure, multistages, stratified
sampling, cluster sampling procedures, etc. The sample size could be determined
with the help of statistical experts.
The size of a sample is related to the objectives, level of precision and the availability of time
and funds. The sampling unit (i.e. the unit selected for field enquiry) may be households,
eligible women, direct beneficiaries of the project etc.
Say, a project covers 20 slum clusters and a population of nearly 50,000. From these
20 slums, if we have to select a random sample of 500 households for collection of
data on maternal and child health conditions and contraceptive usage, we may adopt
the multi-stage stratified sampling procedure. The term multi-stage refers to the selection
of slums at the first stage and then selection of households (from the selected slums) at
the second stage. Stratification refers to the classification of sampling unit (i.e. slums
or households) into several groups so as to make these groups more homogenous. In
other words, if the slums are to be stratified into homogeneous groups, all the slums
with common characteristics may be clubbed under one strata while the ones with
different characteristics may be put under other strata. For the purpose of health projects,
we may consider two strata of villages/slums i.e. slums which have a health facility
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Project Implementation, Monitoring And Evaluation
provided by the government and those which lack facilities. Accordingly, 2 groups of
slums may be formed, each group consisting of 10 slums, and from each group 50
slums may be selected.
After selecting slums at the first stage, 50 households may be selected from each of the
selected slums using either simple random sampling or by systematic random sampling.
In simple random sampling, 50 households may be selected on a random basis so that
these households represent any average household of the slum. On the other hand, in
systematic random sampling all the households in the slum are identified by preparing
house list of all the households and then assigning a household number. After this, a
sampling fraction is calculated based on the number of households to be selected and
the total number of households enumerated in the slum. Using this sampling fraction
or sampling interval, the households are selected in a systematic way with a random
start. For example, in a slum of 200 households, 50 households would be selected at an
interval of 4 households from the random start. If the random start number is 3, then
the households selected in the sample would be every 4th household, i.e. 4th, 7th, 11th,
15th and so on. These households would form the sample households.
The specific tools that are to be used in household surveys should be designed only
after the purposes, objectives and conceptual framework for the evaluation have been
established. The data collection tools should be constructed so that analysis can be
carried out easily.
Generally, in a s-ample survey, a questionnaire is designed and administered to the
sample households to collect the required information. The contents of the questionnaire
depend upon the nature of data which an evaluator wishes to collect from the field. The
number of questions included in the questionnaire should be in accordance with the
cost and time allotted for the survey. These questions may be either in a closed form
(pre coded, multiple answers) or can be open ended. Apart from the levels of health
conditions, the questionnaire should also include questions related to the project
activities, and the likely impact of these activities.
Data analysis includes editing, codification, classification, compilation and tabulation,
statistical manipulation and interpretation of data.
The data collected through questionnaires must be cross-examined for their consistency,
reliability and validity. After proper editing, the data should preferably be transfered
into numerical codes so that it may be fed into the computer for easy analysis. The
purpose of data analysis is to summarise the completed observation. For analysis,
simple computations, viz, percentage distribution, cross-classifications, etc. should be
attempted. Depending upon the need of the evaluation, a more complicated statistical
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• Report Writing
Preparing a comprehensive report is a very crucial aspect. It is only through this report
the activities undertaken in the project, the impact it has made in the community or on
the targeted population, its successes and failures and future implications can be
documented and used for further dissemination.
The report should incorporate the entire experiences of the project implementation
right since its inception till the end, coupled with the results derived through sample
survey. It should contain broadly the major issues like:
~ Background of the project area
~ Need for project implementation
~ Objectives of the project
~ Methodology adopted
~ Activities undertaken in the project
~ End-line evaluation results
~ Describing the methodology adopted to derive a sample
~ Sample results
~ Sustainability
~ Implications of its replicability.
• People's Satisfaction in implementing the project
While evaluating the project activities from the part of the implementing agency, it is
also necessary to incorporate the view points of the community as far as the impact of
the project is concerned. The evaluation exercise must include the level of satisfaction
expressed by the people of the community for whom the whole project was designed.
It is only after assessing their views, and combining them with the evaluation undertaken
by the implementing organisation, the objective conclusions may be drawn.
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Project Implementation, Monitoring And Evaluation
Questions
• What are the steps for successful implementation of the project.
• Do you think monitoring to evaluation helps in improving efficiency of RCH
programmes.
• What are evaluation mechanisms for achieving objectives of health programmes.
• What is the role of indications to feedback in monitoring programmes.
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Financial Management of Projects
FINANCIAL MANAGEMENT OF PROJECTS
t:r Learning objectives
On completion of this module, the participants should be able to :
• Understand the requirements of a Donor Agency
• Write out the components of a Project Budget
• Comprehend Project Accounting System
• Prepare Project Reports
• Prepare Financial Reports
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Introduction
The definition of Management is getting work done through people, but real management is
developing people through work. Thus Management means taking realistic decisions as to
what is to be done based on the given environment and circumstances; then specifying the
material, technology and human resources required to do it; deploying them to its optimum
use and getting the work done through people. This involves forecasting, planning, organising,
motivating, commanding, controlling and coordinating. This broadly indicates the following
functions to a person who performs the role of a manger or is a manager:
• Decision making
• Identifying resources
• Deploying resources
• Inspiring and motivating workers
• Ensuring workers' involvement
Functions of a Project Manager in the middle level
management
Being a middle level manager/coordinator/supervisor one has to perform varieties of roles and
take responsibilities. In reality a manager may not be expected to carry out all these functions,
but (s)he may have to perform some of these functions depending upon his/her position in the
hierarchy ofthe organization. A middle level manager/ supervisor/coordinator in an organization,
generally does not have much decision making role. Although all the important decisions are
taken by the Director of the organization, the middle level managers have to take decisions
regarding the implementation of programmes. Resources are already specified and made
available to him/her. Hence he/she has very little option to make decisions with regard to the
resources, etc. The last two functions, i.e., deploying resources and getting the work done are
his/her prime functions as the middle level manager. Specially the last function of getting the
work done is his/her chief function as the manager. While getting the work done, the manager
has to playa supportive role to the subordinates actually working in the field situation. Out of
several supportive managerial roles, one of the roles (s)he has to carry out is the financial
management while getting the work done. This is a very important role for successful completion
of the assigned work.
One has to often remember the following phrase in this regard:
Beware of Small Expenses.
A small leak can sink a big ship .
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Financial Management of Projects
With this backdrop, this Module deals with the management of accounts handled by middle
level managers while implementing the project. This Module will give the voluntary
organisations receiving project grants a better understanding on how to administer projects
and will clarify a number of recurring questions and issues relating to finance, record keeping,
financial reports etc.
Donor Agency's Financial Philosophy
Financial administration is wrongly regarded as a means to police research activities through
financial controls and restrictive regulations. That is why these days most donor agencies
prefer to encourage a 'Team Approach' in which programme staff work in co-operation with
their financial and administrative counterparts. In this spirit, pertinent financial information is
passed on to programme staff enabling them to work closely with financial staff. Every donor
agency needs regular and detailed financial reports from projects and this information enables
the financial administration to monitor project's progress and to respond quickly to any request
for budget amendment.
Institutions differ in their accounting systems, reporting methods and in their general
administrative practices. But every donor agency expects certain minimum standards though
not wanting the projects to suffer because of overly stringent regulations. The guidelines
prescribed in the module should be interpreted in the light of this philosophy.
General Components of Project Budgeting
The components of a budget for each project vary, depending on the type and complexity of
the project activity. Normally the project costs cover:
(a) Hiring staff specifically for the project;
(b) Hiring casual labour;
(c) Purchasing small tools, materials, field and supplies and any other items needed to
carry out the project activity;
(d) Purchasing capital equipment;
(e) Covering travel costs of project staff to carry out the project activity or to exchange
project related information;
(f) Availing information services through libraries and purchase of books, subscription
to periodicals;
(g) Hiring of consultants to advise the project staff on specific, anticipated problems;
(h) Training cost;
(i) Workshop cost to share the results and findings;
(j) Publication of final report;
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(k) Overheads;
(1) Miscellaneous;
(m) Additional type of project costs may be identified for inclusion in the project budget.
Thus the Standard Project Budget categories can be indicated through the following budget
line items: Salaries, Project Costs, Capital Equipment, ConferenceslWorkshops, Consultants,
Training, Travel, Dissemination, Support services, Overheads and Co-ordination.
Salaries include all remuneration, allowance and benefits paid to the project staff and
advisors hired for a specific project.
• Project Costs
Project costs contain services and materials including reference materials to carry out
the project. It can include: remuneration paid to persons gathering data and information;
maintenance and operation costs of project vehicles, the cost of consumables, cost of
maintenance of other equipment, cost of computer service, honorarium to consultants/
advisors, cost of local travel, cost of casual labour, rent paid for the premises used for
a project activity, cost of casual/part time staff; purchase of video/audio cassettes and
reference material for the project.
This category should cover expenditure on all equipment and furniture that have a
useful life of more than one year.
This covers the costs of attending project related seminars, meetings and coferences
that may be organised by voluntary organisations. Costs include accommodation, travel,
registration fees, catering service, rental for audio visual equipment, honorarium for
paper presentation.
This cover all expenses related to acquiring the services of a consultant for a specific
activity. Persons providing expert professional advice to project staff and who work
on "fee for service" basis and not on salary basis are covered here. Consultants are
persons contracted for shorter period to work on specific assignment. Costs include
fees, travel, accommodation, living expenses and support services hired directly by the
consultant for the project. However, the total cost may be reported as a lumpsum in the
budget line item with an explanatory note .
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FinancialManagementof Projects
• Training
This covers trainee's registration and tuition fees, living and other allowances and travel
costs during his/her participation in short course, field work and other programmes.
Training for project staff that relates to the implementation of a project should be
shown under project cost.
This covers costs incurred by project staff outside the project area.
All local travel expenses for implementing the project is to be reported under Project
Costs. Travel costs specifically related to training, dissemination, evaluation and
co-ordination should be reported under these specific budget items rather than
under travel.
This budget item covers all dissemination activities. It can include the costs of project
related seminars, conferences, meetings that may be organised by the voluntary
organisation for the purpose of disseminating the results of a project. Expenses includes
travel, accommodation, catering service, rental for audio visual equipment, honorarium
for paper presentation, cost of reproduction, publication, distribution etc .
• Support Service
This covers those administrative costs that are not directly related to the project costs.
This can include clerical, accounting, secretarial help, general office expenses, office
rent, utility charge, postage/telephone/telegram etc.
This covers any other expenses which were not covered in the budget. Generally,
support service and overhead expenses are clubbed in the budget.
The co-ordination function involves overseeing the various components of a project to
ensure that all concerned follow the same objectives and approaches including budgetary
monitoring. This covers expense on co-ordination of a project - direct costs of
co-ordinator andhis/her staff.
Accounting System and Records
A project's accounting system should be effective and provide a convenient means for extracting
information for financial reporting. For this the voluntary organisation must account separately
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Reproductive & Child Health Care
for the funds received and for the funds spent on each project. The voluntary organisation's
books of accounts must clearly segregate the information on each project. To facilitate this the
project staff in the field should also maintain separate records for each project.
The basic record kept by most voluntary organisations is a project ledger, which accounts for
expenditure incurred from day to day using the project's budget headings. It is better to use a
budgetary control record that compares budget with actual expense over regular (eg. monthly)
periods. A more detailed variation of the budgetary control record is the fund balance record,
which shows the budget balance of every item after each expenditure.
Treatment of Common Expense in a Multidonor
project:
When a project is funded by more than one donor agency, the accounting for common expense
(i.e. the expenses shared by two or more donors) may be done in one of several ways. For
instance, expenses can be prorated on the basis of each donor agency's approved budget for
specific items (eg. if donor 'A' is to contribute Rs 10,000 and 'B' is to contribute Rs 20,000 to
a Rs 30,000 project, the sharing would be in the ratio of 1:2). Alternatively, expense can be
divided on the basis of total project costs. This approach simplifies accounting because the
total costs are simply split in proportion to the level of funding. However, in both the ways,
the expenses should be accounted for on a day-to-day basis under the respective budget headings
without being split among the donors. To facilitate easy and efficient book keeping, splitting
should be done at the time when the financial reports are being prepared.
Project Reports
The MoG or Memorandum of Grant condition or the project sanction letter for each
project specifies the frequency of reporting, say quarterly, half yearly or yearly - one
on the project's technical progress and the other on its finances. These two reports are
normally submitted at the same time. However, if the project is experiencing cash-
flow problems before the scheduled payment date of the next instalment, the voluntary
organisation should submit its financial report as early as possible.
Financial reports are extremely important. Project Managers must be constantly aware
of the financial status of their projects. Excess funds means that activities have been
either over budgeted or not performed as per the schedule. Fund de fecit means either
that expenditures have been underestimated or that unplanned activities are taking
place. A change in one area of activity usually affects the whole project. Project
Managers, therefore, can use financial information as a measure of the project's overall
progress and as an indicator that could be used to correct problems.
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Financial Management of Projects
The Financial Report should provide enough details for both the recipient and Donor
Agency to appraise the project's financial situation. The Financial Report should:
~ be presented in the same format (Le. using the same budget items. See Appendix
I from page No. 11 to 15 for sample financial report)
~ clearly state the period covered (e.g. from April 1, 1998 to June 30, 1998)
~ report expenditure on a cash basis. Provision for expenses should be included
with the estimates for the next period.
~ include a summary of funds received from Donor Agency, specifying the date of
each instalment received.
~ include estimated expenditure for the next payment period
~ contain a list of capital items purchased
~ include an analysis of variations between budgeted and actual expense as well as
notes explaining any cost overruns on main budget headings
~ include other project income, if applicable
~ provide an analysis of cash position of the project at closing date
~ be signed by the Project Manager and voluntary organisation's Finance Manager.
Estimated Expenses for the Next Payment period
It is important that voluntary organisations submit estimates of expenses for the next payment
period along with the report of actual expenditure. These estimates (including accrued expenses)
give the voluntary organisation the flexibility to modify the schedule of activities. The total
actual and future expense, however, should be within the approved budget limits. The
submission of estimated expenditure also allows the voluntary organisation to seek approval
for any major budgetary changes.
Timely submission and proper presentation of financial reports largely determine the speed
with which the funding agency releases funds.
Delays in Commencement
Normally the project starts either on the date of the Memorandum of understanding/sanction
letter signed or on the date specified therein. However, projects are sometimes delayed because
of difficulties in hiring personnel, preparing facilities, or purchasing essential equipment. In
such cases, as soon as possible, the voluntary organisation should notify the Donor Agency the
actual date of commencement so that a change in the completion date could be considered.
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Budget Revision
Project expenditure should be kept within the approved budget, although unforeseen
circumstances sometimes require changes to ensure that the project meets its objectives.
Normally, there are three types of budgetary change:
When budget needs to be changed to match revisions in the timing of actitivites i.e.
when expenditures on a budgetary item (e.g. salaries) for a particular period differ
from the budget, the budget for the remaining time must be decreased or increased
correspondingly. Most Donor Agencies accept such a change as long as (a) the total
budget for the item is not exceeded; and (b) the overall project objectives
remain unaltered.
When an expenditure exceeds the major budget line items because of inflation,
underestimates, programme changes etc. and if such transfer exceeds the original budget
by 10% or more, the voluntary organisation must justify such transfer and seek prior
approval of the Donor Agency.
For introducing new line items during the project duration, the voluntary organisation
should submit requests giving justification and seek Donor Agency's approval.
• To avoid budget overruns
The voluntary organisation must ensure careful planning and estimation at the time of
project's conception and implementation.
Disposition of Project Income
Certain projects generate income from interest paid on bank depositslbalances or from the sale
of certain items/scrap or publications etc. All income must be properly accounted for; reported
to the Donor Agency and included in the analysis of the cash position of the project at the
reporting date.
Accounting System at Field Level
At the field level the Project Manager receives funds from the Head Office (H.O.) and incurs
expenditure connected with the implementation of the programme. The Project Manager at
the field incurs expenditure directly and through his field staff. For easy, efficient and accurate
financial management of the project, the Project Manager at the field must maintain a daily
diary of activities and of finance/accounts .
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Financial Management of Projects
• Daily Diary
The daily diary for finance/accounts should have the following three heads:
(i) cash expenses
(ii) advances
(iii) provision for committed expenses i.e.pending billsfor which payments are yet
.to be made
(i) Cash Expenses
Cash expenses should be noted datewise on a daily basis. For every payment
cash memos/bills and official receipts must be obtained wherever possible. If
the Project Manager/project staff are unable to obtain cash memos/official receipt
due to valid reasons, they should get the payment acknowledged in the printed
receipt voucher of the voluntary organisation (See Annexure IT for Sample Receipt
Voucher).
(ii) Advances
While giving advances to field staff, to meet project expenses the Project Manager
should obtain the receipt voucher signed by the concerned staff. Field staff taking
advance should render account within one week. After receiving the accounts,
the Project Manager will pay the balance to the staff if the expenditure is in
excess of the advance or receive the balance cash along with the accounts. Then
Project Manager will write the expenditure in the Daily Diary under cash expenses
and cancel the relevant advance entry and the receipt voucher with a remark
'adjusted on
.' (date). For better internal control, advances for expenses
shall be paid only if NO previous advance remains unadjusted.
(Ui) Provision for Committed Expenses
In some project areas, arrangements for printing and stationery with suppliers/
POL (Petrol/OillLubricants) for project vehicles with petrol pumps are made on
credit basis. In such cases where bills are received but payments are to be made
at a later date, the Project Manager should note down this detail under provision
for committed expenses. Whenever these bills are paid the entry should be made
under cash expense on that date and the entry at the provision should be cancelled
with a remark paid on
(date).
• Anticipated Expenditure on field work
Based on the activities in the field, the Project Manager should plan his expenditure for
the next three months and send his requisition for funds in advance along with duly
supported expenses statement and petty cash reconciliation. If there is any major
deviation in the requirement from the budget provisions, Project Manager should explain
the variance to facilitate early release of funds.
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Questions
1. Each project funds are to be accounted separately
2. Financial information is a measure of the projects'
overall progress
3. Financial report should be presented in the same
format i.e. using the approved item line budget
4. Project Managers must be constantly aware of the
Financial Status
5. Expenditure exceeds budget due to programme change/
6. For easy and efficient accounting splitting of common
expenses on multi donor project to be done
7. Cash advances to be included in petty cash disbursement
8. In Petty cash reconciliation balance on hand for
the closing dateofthe 1st reporting period will
be the opening balance for the 2nd reporting period
TruelFalse
TruelFalse
No/Yes
TruelFalse
TruelFalse
at the end!
on a daily
basis
YeslNo
TruelFalse
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Financial Management of Projects
Sample Financial Report
Title of the Project:
Ref. No.
I Budget and Expenditure
Items (ii)
BUdget
Actual
(iii) Expense (iv)
Salaries
Project Director (one)
Research Associate (3)
Project Cost
Advisor
Part time staff
Printing and Stationery
Local Travel
Consultants
Conferences
30,000
45,000
12,000
10,000
6,000
12,000
6,000
0
30,000
45,000
10,000
9,800
5,000
10,800
6,000
0
TOTAl
1,21,000
1,16,600
Variance Explanation
(v) for Variance (vi)
-
-
2,000
200
1,000
1,200
.
-
0
4,400
(i) covers the past year (12 month period)
(ii) use exact budget headings as detailed in the sanctioned project budget
(iii) use budget figures from sanction letter
(iv) actual cash expenses are to be reflected
(v) difference between (iii) and (iv)
(vi) reason for over runs/under runs/new items.
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II Sample Summary of Receipts from Donor Agency
Project Title:
Ref. No.
51.No.
1.
2.
Date
10 April 19
4 Oct 19
Amount
60,000
60,000
Total
1,20,000
III Statement of Estimated Expenses for the period
(i) from _ to_
Items (ii)
Budget
(m)
Salaries'
Project Director (one) 30,000
. Research Associate (3)
Project Cost
45,000
Consultant
12,000
Part time staff
10,000
Prin ting and Stationery 6,000
Local Travel
12,000
Consultants
6,000
Conferences
0
TOTAL
1,21,000
Estimated Estimated
Expenses Variance
(iv)
(v)
30,000
-
45,000
-
14,000
10,000
7,000
12,000
6,000
0
-
1,24,000
(-) 200
-
(-) 1,000
-
-
0
(-) 3,000
Explanation of
Estimated
Variance
(vi)
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FinanciaMl anagemeonftProjects
(i) covers the next year (12 month period) or for remaining project duration if less than one year
(ii) use exact budget headings as detailed in the sanctioned project budget
(iii) use budget figures from sanction letter
(iv) estimates based on latest project plans
(v) difference between (iii) and (iv)
Fund Position as on (i)
Balance as on (ii)
Add Received during the period
(Hi) from
to
Less Actual Expenditure during the
period (iii) from __ to_
Balance in Bank/Cash
Less Estimated expenses for the
period (iv) from __ to __
Amount of grant required to meet
estimated expenses (v)
(iv) Estimated expenses covering the next year (12 month period) or for remaining project duration if
less than one year
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V Petty Cash Reconciliation
Petty Cash is reconciled when two petty cash on hand balance equal. This form
should be reconciled monthly and maintained on file.
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FinancialAianagelnentofProjects
(c) Total Receipts
(d) Closing Balance
(Becomes opening balance for the
next period)
I (a) Closing balance as per Bank statement
(b) Less outstanding cheques as per list
(c) Add Deposits in transit
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Reproductive ~ Chi4l.!lea~h l:lfre.
I I ANNEXURE - II
Received a sum of Rs
by Cash/Cheque No
dated
(Rupees
)
from 'X' voluntary
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