Family welfare in India

Maternal, newborn, and child health programmes in India are integrated under the RMNCAH+N strategy (Reproductive, Maternal, Newborn, Child, and Adolescent Health + Nutrition) framework, which promotes a continuum of care across the life cycle through financial incentives, community-based monitoring, and standardized clinical protocols.

RMNCAH+N strategic framework

The management of maternal and child health in India is guided by the RMNCAH+N strategy. This framework adopts a continuum-of-care approach across the life cycle and levels of care, emphasizing that interventions at one stage influence outcomes at subsequent stages and integrating services from the community to tertiary facilities.

Implementation framework

• Core philosophy: continuum of care across the life cycle and levels of care
• Vertical integration: linking services from the community level (Accredited Social Health Activists, Anganwadi) to primary health centers and higher referral facilities (e.g., first referral units)
• Horizontal integration: convergence with nutrition, sanitation, and education programs to address social determinants of health

National family planning programme

The national family planning programme in India promotes the use of contraception among eligible and target couples to achieve a stable population. The program aims to increase the couple protection rate to reach replacement-level fertility.

Programmatic targets

The welfare program follows a sequence of indicators to monitor its impact on population growth.

• Couple protection rate: Target > 60%
• Total fertility rate: Target < 2.1
• Net reproduction rate: Target 1 (replacement level)

Eligibility and objectives

• Eligible couple
  • Couples with a woman in the reproductive age group (15–49 years)
  • The ideal family planning method is contraception
• Target couple
  • Couples who have a completed family with at least one living child and are likely to adopt a permanent family planning method
  • The ideal family planning method is sterilization

Contraceptive effectiveness (Pearl index)

• Most common method used to measure the failure rate per 100 women-years of exposure
• Calculated as (number of accidental pregnancies / total woman-years of exposure) × 100 or using months (number of pregnancies / total woman-months of exposure) × 100 x 12
• Life table analysis is considered the gold standard for measuring contraceptive failure.

Temporary contraceptive methods

These methods are used for spacing births and include barriers, hormonal agents, and intrauterine devices.

• Intrauterine devices: see "Intrauterine devices" in "Contraception."
• Hormonal contraceptives: see "Hormonal contraception" in "Contraception."
• Barrier methods: see "Barrier methods of contraception" in "Contraception."
• Behavioral methods: see "Behavioral methods of contraception" in "Contraception."
• Emergency contraception: see "Emergency contraception" in "Contraception."
• Nonhormonal oral contraceptive
  • Ormeloxifene
    • A selective estrogen receptor modulator developed by the Central Drug Research Institute in Lucknow
    • Dose: 30 mg twice weekly for 3 months, then once weekly
    • Adverse effects: menstrual irregularities (e.g., amenorrhea) and vasomotor symptoms (e.g., hot flashes)

Permanent contraceptive methods

• See "Surgical sterilization" in "Contraception."

Contraceptive of choice

Recommendations are based on the user's specific life stage and clinical needs.

• All females (regardless of breastfeeding status)
  • IUD within 48 hours or after 6 weeks postpartum
  • Female sterilization within 1 week or after 6 weeks postpartum
  • Emergency contraception up to 4 weeks postpartum
• Delay of first child: OCP (preferred); IUD as an alternative
• Delay of second child: IUD (preferred); OCP as an alternative
• Breastfeeding individuals
  • Progestin-only contraception (POC) anytime postpartum
  • Depot medroxyprogesterone acetate (DMPA) after 6 weeks
  • OCP after 6 months
• Non-lactating postpartum individuals
  • POC or DMPA anytime postpartum
  • OCP after 3 weeks
• Married couples with infrequent sexual contact: IUD (preferred); OCP as an alternative; DMPA if the other methods are unsuitable
• Unmarried individuals: barrier methods ± OCP

Initiatives

• Mission Parivar Vikas: promotes access to modern contraceptives, including DMPA, OCPs, IUCDs, emergency contraceptive pills, condoms, and sterilization, in high-fertility districts.
• National Family Welfare Programme
  • Nishchay kits: used for home and field pregnancy testing
  • Scheduled service delivery approach for sterilization
    • Primary health center: monthly
    • Community health center: every 2 weeks
    • Sub-district hospitals: weekly
    • District hospitals: twice per week
• Medical eligibility criteria wheel
  • A WHO-based tool used to assess the safety of contraceptive methods
  • Scores range from 1 (no restriction) to 4 (unacceptable health risk)
• ASHA incentives
  • ₹500 for maintaining a 3-year gap between children or delaying the first child for at least 2 years after marriage
  • ₹1,000 for adopting a permanent contraceptive method after the second child
  • Home delivery incentives: ₹1–5 for every three condoms distributed and ₹3–5 per OCP packet

Maternal health interventions in India are designed to ensure safe motherhood through high-quality antenatal care, institutional delivery, and postnatal support. These services are delivered through a combination of clinical care models, financial incentive schemes, and community-based monitoring.

Antenatal care (ANC)

Standard protocols ensure the early identification of high-risk pregnancies and the maintenance of maternal nutrition.

• ANC visits
  • Minimum ANC: 4 visits (at ≤ 12 weeks, 14–26 weeks, 28–34 weeks, and ≥ 36 weeks)
  • WHO care model: 8 visits (1st trimester: 1; 2nd trimester: 2; 3rd trimester: 5)
  • Recommended ANC: 13–14 visits (monthly visits up to 7 months of gestation, fortnightly visits in the 8th month, and weekly visits in the 9th month)
• Nutrition
  • An average increase of + 350 kcal/day is recommended during pregnancy
  • See "Nutrition and weight gain" in "Prenatal care."
• Immunization schedule
  • If last pregnancy > 3 years ago or no complete prior immunization: 2 doses of tetanus toxoid IM (0.5 mL each), given 4 weeks apart
  • If complete immunization within the past ≤ 3 years: Single booster dose of tetanus toxoid
  • See "Immunizations in pregnancy and lactation" in "Immunization schedule" for additional recommendations.
• Screening: See "Screening for medical comorbidities" in "Prenatal care."
• Gestational diabetes mellitus: See "Diagnosis of diabetes in pregnancy" in "Diabetes mellitus in pregnancy."

Clinical care models

Specialized initiatives focus on expanding access to specialist care and improving the quality of labor room services.

• PMSMA (Pradhan Mantri Surakshit Matritva Abhiyaan)
  • Provides free ANC check-ups on the 9th of every month
  • Cases are categorized using color-coded stickers:
    • Green: no risk factors
    • Red: high-risk pregnancy
    • Blue: pregnancy-induced hypertension
    • Yellow: comorbid conditions (e.g., STI, hypothyroid, DM)
• SUMAN (Surakshit Matritva Aashwasan)
  • A service guarantee initiative ensuring zero-expense, respectful care
  • Provides free ANC, delivery, postnatal, and newborn care services (e.g., support for breastfeeding, zero dose vaccination), along with free treatment for sick neonates and complementary transport
  • Mandates a zero tolerance for denial of services
• LaQshya: A quality improvement initiative focused specifically on labor rooms and maternity operation theaters

Financial incentive and benefit initiatives

India utilizes targeted schemes to reduce the out-of-pocket expenditure associated with childbirth and to promote institutional delivery.

Nutrition and anemia control

Anemia Mukt Bharat program

See "Anemia control in children and maternal populations in India."

Mother’s Absolute Affection

This program is an Indian adaptation of the Baby-Friendly Hospital Initiative from UNICEF, and focuses on optimal infant feeding practices.

• Early initiation: Breastfeeding should start within 1 hour for vaginal delivery and within 4 hours for cesarean section
• Exclusive breastfeeding: Infants should receive only breast milk for the first 6 months of life.

Newborn and child health interventions in India focus on reducing neonatal and under-five mortality through integrated screening, home-based monitoring, and the specialized management of malnutrition.

Mortality indicators and targets

India tracks specific pediatric indicators with the goal of achieving sustainable development goals by 2030.

• Neonatal Mortality Rate
  • Current: 19 per 1,000 live births
  • Target: < 12 per 1,000 live births
• Under-five Mortality Rate
  • Current: 29 per 1,000 live births
  • Target: < 25 per 1,000 live births
• Infant Mortality Rate:
  • Current: 25 per 1,000 live births

Home-based monitoring

The ASHA provides community-level oversight through scheduled home visits to identify illness and monitor growth.

• Home-based newborn care
  • Facility-based vaginal delivery: 6 visits (Days 3, 7, 14, 21, 28, and 42)
  • Home delivery: 7 visits (Days 1, 3, 7, 14, 21, 28, and 42)
  • Cesarean section: 5 visits (Days 7, 14, 21, 28, and 42)
• Home-based care for a young child
  • Conducted for children aged 3–15 months
  • It involves 5 visits at 3, 6, 9, 12, and 15 months.

Rashtriya Bal Swasthya Karyakram (RBSK)

• An initiative for children aged 0–18 years aimed at early identification and intervention for the "4Ds":
  • Defects at birth
  • Deficiencies (e.g., Vitamin A, Iron)
  • Diseases of childhood (e.g., skin conditions, otitis media)
  • Developmental delays and disabilities
• Linked with the Ayushman Bharat initiative
• Implemented through schools, anganwadi centers, and juvenile homes

Rashtriya Kishor Swasthya Karyakram (RKSK)

• A national adolescent health program targeting individuals aged 10–19 years, focusing on preventive and promotive health services
• Delivered through adolescent-friendly health clinics
• Interventions provided:
  • Weekly iron and folic acid supplementation
  • Menstrual hygiene promotion
  • Peer-led education (Saathiya approach)

Navjat Shishu Suraksha Karyakram (NSSK)

The NSSK is a program focused on improving neonatal outcomes by offering healthcare providers training in essential newborn care and resuscitation.

Anemia control in children and maternal populations in India

The Anemia Mukt Bharat program follows a 6 x 6 x 6 strategy (6 beneficiaries, 6 interventions, and 6 institutional mechanisms) to reduce the prevalence of anemia. A central component is prophylactic iron-folic acid supplementation using a color-coded system for different age groups.

Key interventions

• Iron-folic acid prophylaxis
• Biannual deworming
  • On national deworming days: February 10 and August 10
  • Age-appropriate dosing of albendazole is provided:
    • 1–2 years: albendazole 200 mg
    • > 2 years: albendazole 400 mg
• Behavior change communication: healthy body, sharp mind

Iron–folic acid prophylaxis:

• Pregnant and lactating women: 60 mg iron + 500 μg folic acid daily; red tablets
• Women (20–49 years): 60 mg iron + 500 μg folic acid weekly; red tablets
• Children (6–59 months): 20 mg iron + 100 μg folic acid biweekly; liquid formulation
• Children (5–9 years): 45 mg iron + 400 μg folic acid weekly; pink tablets
• Adolescents: 60 mg iron + 500 μg folic acid weekly; blue tablets