National policy,legislation in relation to maternal health and welfare

NATIONAL POLICY,LEGISLATION
IN RELATION TO MATERNAL
HEALTH AND WELFARE
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MATERNAL HEALTH IN
MEDEVIAL PERIOD
 Dates back to Vedic period between
3000BC – 1400BC
 Indus valley civilization showed relies of
planned cities and healthful living.
 Ayurveda and other system of medicine
practices by sages suggests
comprehensive concept of health.
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 272 BC-236 BC King Ashoka a covert of
Buddhism built a number of hospitals.
Midwives were given a lot of preference
during his time. They were considered
to be skillful and trustworthy.
 200-300AD Sushruta also defines ideal
relationships.

 500-600 AD Vagbhata wrote Ashtanga
Hridaya (8 limbs and heart). Potency
and procreative ability was one of the
branch of the 8 limbs.
 This book is the most concise exposition
of Ayurveda.

 1300-1600 AD Bhavaprakasha a
renowned Indian treatise contains an
exhaustive list of disease and their
symptom and a complete list of drugs.
 It includes etiology and treatment of
syphilis a disease brought to India by
Portuguese seamen.

Maternal health in Pre-
Independence period
 1873-Birth and death registration Act was
passed.
 1880-Vaccination Act was passed.
 1931-Maternity and child welfare Bureau
was established under the Indian Red
Cross.
 1946-Bhore Committee report was
submitted.

 Republic of India is a federal Republic (union
of states)
 Indian Central Government has focussed on
improving health of people since
independence.
 Life expectancy was 60 years then compared
to 69 years at present.
 Infant mortality rate was 150 compared to 32
at present.

 A wide variety of programs were intended
for vaious parts of the country to improve
welfare of women and children.

Terms
 Policies: course of actions, programme
of actions adopted by a person, group
or government.
 Policy Environment: the arena the
process takes place
in, government, media, public
 Policy Makers

Policy making in health
administration
 Gives a concrete shape to political and social
objectives which government lays down in
the form of laws, rules and regulations.
 It defines the objectives and determines the
choice of actions.
 While formulation of any policy government
appoints an expert committee for decision
making.

 Eminent persons from different
specializations may be appointed to
constitute a committee.
 Views of the committee have an
influence on policy making.

Stategies for health planning
 Constitution of India
 National development Council
 Planning Commission
 Advisory Bodies
 Ministry of health and family welfare

 Health care measures formulated and
implemented in the successive 5 year
plans were based on approaches
recommended by health Committees
constituted by Government of India.

Committees and comissions
 NPC committee on National Health (Col
Santok Singh Sokhey)
 Health Survey and development
committee (Sir Joseph Bhore)
 Nursing Committee to review conditions
on nursing (Shri Shetty 1954)
 Special Committee on NMEP (Dr. MS
Chadda)

 Committee to review strategy of family
planning (Shri Mukherjee)
 Committee on integration of health services
(Dr Jungulwala)
 Committee for reviewing staffing pattern and
financial provisions for FFP (Shri Mukherjee)
 Committee on Multipurpose workers
under H and FW (Kartar Singh)

 Group on medical education and Support Manpower
(Dr.JB Shrivastava)
 National health Policy(1983)
 Medical education review Committee (Shri Mehta)
 Working group on Medical education and training
Manpower (Planning Comission)
 Committee on Health Manpower planning (Dr.Bajaj)
 High Power Commission on nursing and Nursing
Profession (Sarojini Varadappan)

Development of legislation in
midwifery education
 William Rathbone formed Visiting
Nurse‟s Association at England.
 It is influenced in India, because of
terrible condition, under which children
were born recognised as cause for high
mortality rate. Because untrained „Dais‟
are attending women at the time of
child birth.

 Dais were unwilling to trained and
patients will to accept the old
customary methods. In 1926 –
Midwives Registration Act formed for
the purpose of better training of
midwives.

ESTABLISHMENT OF INDIAN
NURSING COUNCIL
 The INC was constituted to establish a
uniform standard of education for
nurses, midwives, health visitors and
auxiliary nurse midwives. The INC act
was passed following an ordinance on
December 31st 1947 . The council was
constituted in 1949.

MAIN PURPOSES OF THE
COUNCIL
1. To set standards and to regulate the
nursing education of all types in the country.
2. To prescribe and specify minimum
requirement for qualifying for a particular
course in nursing.
3. Advisory role in the state nursing council
4. To collaborate with state nursing councils,
schools and colleges of nursing and
examination board.

STATE REGISTRATION
COUNCIL.
 1. Inspect and accredit schools of
nursing in their state .
2. Conduct the examinations
3. Prescribe rules of conduct.
4. Maintain registers of
nurses, midwives, ANM and health
visitors in the state.

RECOMMENDATIONS OF VARIOUS
COMMITTEES PERTAINING TO NURSING
EDUCATION.
1. Health survey and development
committee ( Bhore committee 1946)
a. Establishment of nursing college.
b. Creation of an all India nursing
council.

 2. Shetty committee 1954
a. Improvement in conditions of
training of nurses.
b. Minimum requirement for admission
to be in accordance with regulation of
the INC.

Health Survey and planning
committee(Mudhaliar Committee 1959-
61)
1.Three grades of nurses viz. the basic nurses
(4yrs), auxiliary nurse midwife (2yrs) and
nurses with a degree qualification.
2.For GNM minimum entrance qualification
matriculation .
3.For degree course passed higher
secondary or pre university.
4.Medium of instruction preferably English in
General nursing.
5.Degree course should be taught only in
English.

4. Mukherjee
committee, 1966.
 a. Training of nurses and ANM‟S
required for family planning.
5. Kartar singh committee,1972-73
a. Multipurpose health worker scheme
b . Change in designation of ANM‟s and
LHV
c. Setting up of training division at the
ministry of health and family welfare

7. Sarojini varadappan committee, 1990
(A high power committee on nursing and
nursing profession.)
 a. Two levels of nursing personnel
b. Post basic BSc nursing degree to
continue
c. Masters in nursing programme to be
increased and strengthened.
d. Doctorate in nursing programme to
be started in selected university.
e. Continuing education and staff
development for nurses.

8. Working group on nursing
education and manpower,1991.
 a. By 2020 the GNM programme to be phased
out
b. Curriculum of BSc nursing to be modified
c. Staffing norm should be as per INC
d. There should be deliberate plan for
preparation of teachers MSc/Mphil and PhD
degrees.
e. Improvement in functioning of INC
f. Importance of continuing education for
nurses.

DEVELOPMENT OF NURSING
EDUCATIION.
 Training of dias
The Dai training continued past
independence. The goal was to train one Dai
in each village and ultimate goal was to train
all the practicing Dais in country
Duration of training was 30 days. No age limit
was prescribed, training include theory and
practice, more emphasis on field practice.
This training was done at sub centre and
equipments provided by UNICEF.

Auxillary Nurse Midwife
 In 1950 Indian Nursing Council came out with an important decision
that there should be only two standard of training nursing and
midwifery, subsequently the curriculum for these courses were
prescribed.
The first course was started at St. Mary's Hospital Punjab,1951.The
entrance qualification was up to 7/8 years of schooling. The period of
training was 2 years witch include a 9 month of midwifery and 3
months of community experience.
In 1977, as a result of the decision to prepare multipurpose health
worker& vocationalization of higher secondary education, curriculum
was revised a designed to have 1.5 year of vocationalzed ANM
programme and six months of general education. The entrance
qualification was raised from 7th passed to matriculation passed.
Under multipurpose scheme promotional avenue was opened to senior
ANMS for undergoing six months promotional training for which course
was prescribed by INC.

 Training of LHV course continued post
independence. The syllabus prepared
and prescribed by INC in 1951.The
entrance qualification was
matriculation. The duration was two
and a half years which subsequently
reduced to 2 years.
Lady Health Visitor Course

General Nursing And Midwifery Course
 GNM course existed since early years of century.
 In 1951,syllabus was prescribed by INC.
 In 1954 a special provision was made for male nurse.
 First revision of course was done in 1963. The
duration of course was reduced from 4 years to 3.5
years.
 Second revision was done in 1982. The duration of
the course reduced to 3 years.
 The Midwifery training of one year duration was
gradually reduced to 9 months and then six months,
finally three year integrated programme of GNM was
prescribed in 1982.

Post-Basic/Post Certificate Short-
Term Courses And Diploma
Programmes
 The ultimate aim of all the post-basic/
post certificate programme is to
improvement of quality of patient care
and promotion of health.

University-Level Programmes.
 Basic BSc Nursing
First university programme started just before
independence in 1946 at university of Delhi and CMC
Vellore.
INC prescribes the syllabus which has been revised
three times,the last revision was done in 1981.It was
done on basis of the 10+3+2 system of general
education.
 At present the BSc Nursing programme which is
recommended by the INC is of four years and have
foundations for future study and specialization in
nursing.

Post Basic BSc Nursing
 The need for higher training for certificate nurses
was stressed by the Mudaliar Committee in1962. Two
years post basic certificate BSc(N) programme was
started in December 1962.
 For nurses with diploma in general and midwifery
with minimum of 2 years experience.
 First started by university of Trivandrum.
 At present there are many colleges in India offering
Pc BSc(N) Course.

Post Basic Nursing by Distance Education
Mode.
 In1985 Indira Gandhi National open
university was established. In1992 Post
Basic BSc Nursing programme was
launched, which is three years duration
course is recognized by INC.

Post- Graduate Education-MSc
Nursing
 First two years course in masters of
nursing was started at RAK College of
Nursing in 1959.and in 1969 in CMC
Vellore. At present there are many
colleges imparting MSc Nursing degree
course in different specialties.

M.Phil
 INC felt need for M.Phil programme as
early on 1977,for this purpose
committee was appointed.In 1986 one
year full time and two years part time
programme was started in RAK College
of nursing Delhi.

Ph.D in Nursing
 Indian nurses were sent abroad for Ph.
D programme earlier. From1992 Ph D in
nursing is also available in India.MAHI
is one of the university having PhD
programme.

Nurse practitioner in Midwifery

 RCH (phase I) was launched in October
1997
 It incorporates the components covered
under Child survival and safe
Motherhood and an addition component
of reproductive tract infection and
sexually transmitted diseases.

Targets and achievment in
RCH 1 (in %)
Indicator Baseline Target Estimate
IMR 74 60 63
Contracept
ive rate
47.7 60 52
Inst delv 35 60 40
Children
immun
52 60 44.6
Not using
FP
19.5 Less than
10
15.9

 National Population Policy 2000 stressed the
importance to bring down maternal mortality
rate.
 Policy recommends a holistic strategy for
bringing about total intersectoral coordination
at grassroot level and involving NGO‟s ,Civil
Societies,Panchayat Raj institutions and
womens group.

Maternal mortality
Country Ratio
India 407
Sweden 8
UK 10
Greece 2
Sri Lanka 60
China 60
Thailand 54

MMR (India)
States Ratio
UP 707
Rajasthan 670
MP 498
Bihar 451
Assam 409

Maternal Health Indicators
 Antenatal checkups
 Institutional delivery
 Delivery by trained personnel

RCH Phase II
 Begun from 1st April,2005.
 Focus is to reduce maternal and child
mortality with emphasis on rural health care.
 Fifty percent of PHC‟s and all CHC‟s will be
made operational as 24 hours delivery
centres in a phased manner by 2010.
 These centres will provide basic emergency
obstetric care and essential newborn care.

Essential Obstetric care
 Institutional delivery
 Skilled attendant at delivery
 Policy decisions
 Operationalising emergency care
obstetrics

Other Maternal health
interventions
 MTP
 RTI/STD‟s
 Infection management and
enviournment Plan(IMEP)

NEW INITATIVES
 Training of MBBS doctors in Life Saving
Anesthetic skills for emergency
Obstetric care
 Setting up of blood storage in FRU‟s
 ASHA‟S
 Janani Sureksha Yojna(JSY)

Scale of assistance per
delivery
Categ
ory
RURAL AREA URBAN AREA
Moth
er‟s
packa
ge
ASHA‟
s
Packa
ge
Total
Rs
Moth
er‟s
packa
ge
ASHA‟
s
Packa
ge
Total
Rs
LPS 1400 600 2000 1000 200 1200
HPS 700 700 600 600

Independent nurse
Practitioner
 18 month post basic diploma in midwifery
 Imparts all necessary skill to handle obstetric
emergencies
 Authorised to and can establish independent
practise
 Course has been pilotes in West Bengal and 2
of 4 trainees were assigned to a CHC to
manage obstetric emergencies
 Eg:Srilankan Experience

Other suggestions with regard
to nursing education
 A dedicated Nursing and Paramedical Manpower
Division / Unit should be established at the
National and State levels.
 All medical colleges should be mandated to
establish a College of Nursing offering courses in
B.Sc. Nursing, M. Sc. Nursing and Post-Basic
Diploma courses in specialty nursing areas.
 All District Hospitals should be mandated to
establish a school of nursing offering ANM and
Diploma in General Nursing and Midwifery,
 Smaller hospitals in public sector having at least
30 OBG beds should be encouraged to start ANM
training

1. The NRHM has adopted a set of revised staffing norms for the
Sub-centres, PHCs and CHCs which will add to the human
resource needs in the rural areas. For the ANM, the
requirement has doubled as 2 ANMs have been sanctioned for
every Sub-centres. The Sub-centre will continue to be the
critical facility for the delivery of health care of women and
children in rural and remote areas where no other facility
exists. The objective of making 2000 facilities as fully
functional FRUs will require at least 2000 specialists in OBG,
anesthesia and pediatrics (each) and 20,000 staff nurses. The
objective of making 10,000 PHCs as 24/7 facilities equipped
for institutional delivery implies an additional requirement of
30,000 Public Health Nurse Practitioners / General Nurse and
Midwives (GNMs). The NRHM provides for additional
manpower at CHC, PHC & Sub-Center levels.

Standing orders for first aid
obstetric care
 In order to save life of women with
obstetric emergencies,ANM is allowed
to use the following drugs:
 Inj. Oxytocin
 Inj. Magnesium sulphate
 Misoprestol oral
 Inj. Ampicillin

Strengthen skills of ANMs in improving
quality of ANC, especially for
counseling.
 Introduce sticks-based rapid estimation of
hemoglobin and urine examination.
 Provide mother-baby linked card to all,
depicting key messages apart from clinical
information.

INDIAN LEGISLATIVE POLICY
 Legislative programme:approved by
parlimentary affairs department.
 Scope of bill is determined
 Acceptance by cabinet
 Formation of legislative policy
 Refrence to law department
 Decision by Minister in charge in consultation
with law
 Summary to cabinet drafted

Acts in Obstetric Practise
 MTP
 Government of India set up the Shantilal Shah
Committee in 1964 to decrease the highmaternal
morbidity and mortality associated with
illegalabortions, which, after deliberating on a wide
range of evidence over 2 years, recommended a
broadening and rationalisation of laws related to
abortion in 1966. MTP Bill was introduced in Rajya
Sabha in 1969, referred to Select Joint Committee
Review and finally passed as the MTP Act in 1971
and implemented in April 1972. Main objective of
MTP Act of India is reduction maternal morbidity due
to illegal unsafe abortions.

 According to Section 3, Subsection (2) of the MTP
Act, pregnancy may be terminated for the following
indications:
 a) As a health measure, when there is a danger to
the life or risk to physical or mental health of the
woman including rape and failure of contraception.
b) On humanitarian grounds, such as when
pregnancy arises from a sex crime like rape or
intercourse with a lunatic woman, etc and
c) Eugenic grounds when there is a substantial risk
that the child, if born, would suffer from deformities
and diseases.

 According to Section 3, Subsection (2),
for pregnancies up to 12 weeks. the
certification of one qualified doctor is
sufficient but for pregnancies between
12-20 weeks, two doctors must give
their approval. Termination by medical
methods of abortion is approved by GOI
till 49 days of gestation.

 The necessary qualification of a medical
practitioner registered with the State are
broadly defined in Section 2, Clause (d) of the
MTP rules:
 a) Postgraduate degree or diploma in
Obstetrics and Gynaecology.
b) Registered before commencement of the
Act with over 3 years experience in the
practice of Obstetrics and Gynaecology.

 THE PRE-CONCEPTION & PRE-
NATAL DIAGNOSTIC TECHNIQUES
(PROHIBITION OF SEX
SELECTION) ACT – 1994.

 “ An Act to provide for the prohibition of sex selection , before or after
conception, and for regulation of pre-natal diagnostic techniques for
the purpose of detecting genetic abnormalities or metabolic disorders
or chromosomal abnormalities or certain congenital malformations or
sex-linked disorders and for the prevention of their misuse for sex
determination leading to female feticide and for matters connected
therewith or incidental thereto”.
This Act may be called “the Pre-Natal Diagnostic Techniques
(Regulation and Prevention of Misuse) Amendment Act, 2002.
It shall extend to the whole of India except the State Government of
Jammu and Kashmir.

 The Pre-Natal Diagnostic Techniques (Regulation and
Prevention of Misuse) Act, 1994 is an Act to provide for the
regulation of the use of pre-natal diagnostic techniques for the
purpose of the detecting genetic or metabolic disorders or
chromosomal abnormalities or certain congenital malformations
or sex-linked disorders and for the prevention of the misuse of
such techniques for the purpose of pre-natal sex determination
leading to female foeticide; and for matters connected therewith
or incidental thereto. Under Section 2(i) of that Act “pre-natal
diagnostic procedure” means all gynaecological or obstetrical or
medical procedure such as ultrasonography, foetoscopy, taking
or removing samples of amniotic fluid, chorionic villi, blood or
any tissue of a pregnant woman for being sent to Genetic
Laboratory or Genetic Clinic for conducting pre-natal diagnostic
tests.

Monitoring through NRHM
 Community awareness through ASHAs,
 integration of the issue in training modules and
programme and in IEC material,
 adding information on sex selection to the medical
curriculum,
 including indicators on improvement in sex ratios
and birth registration as a part of monitoring
target/indicators under RCH 2/NRHM

The Consumer Protection Act,
1986
 The aims and objects of the Act as
given in its Preamble, inter alia are: the
better protection of the interests of the
consumers and for settlement of
consumer disputes.

 Deficiency in medical services gives
patient as a consumer the right to claim
compensation.
 The consumer Protection Act is a piece
of comprehensive legislation and
recognises six rights of consumers .

 Right to safety
 Right to informed
 Right to choose
 Right to be heard
 Right to seek compensation
 Right to consumer education

Legal issues in maternity
practise
 Licence to conduct delivery
 Refer complicated cases appropriately
 Monitoring of mother and fetus adequately
 Assist in MTP but can refuse in cases of moral
offense.
 Proper identification of mother infant pair
with finger prints,foot prints and wasit bands
as per hospital policy.

 Surrogate mother lenting out her uterus for
fertilised ovum also possess ethical issues
mainly about monetary compensation.
 In artificial insemmination maintain
confidentiality about donor and recipient.
 It is considered unethical if conception is
aimed at use of embryo for research purpose
only.

Legal safeguards as a staff
 Licensure
 Good Samaritarian Law
 Standards of care
 Standing orders

Woodrow Wilson,American
President
We grow great by dreams. All big men are
dreamers. They see things in the soft haze of a
spring day or in the red fire of a long winter's
evening. Some of us let these great dreams
die, but others nourish and protect them;
nurse them through bad days till they bring
them to the sunshine dreams will come true

Thank you

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