Auxiliary nurse midwife (ANM) at subcenter was recording survey and packages of service utilization data in as many as thirteen registers. Government of India, MoHFW, consolidated all the service record registers into one register in 2017 named as Integrated Reproductive and Child Health Register (IRCHR). In view of several new programs and developments, the IRCHR of 2017 was further updated and revised and named as IRCHR Version 2.0. This was released in June 2022 for implementation by all the states/UTs in India. This obviated the need for ANM to collect and maintain the information on various aspects—family planning, maternal health, child health, immunization, births, and deaths in multiple registers often resulting in entering similar information in multiple registers leading to duplication of ANM efforts and time and of course money on printing. Essentially, IRCHR integrates many service record registers into one register. It connects essential maternal, newborn, and child health packages of service across reproductive years (15-49 years), pre-pregnancy, pregnancy, childbirth, post-natal and newborn into childhood, and adolescence phase of life (a life cycle approach). It also integrates and links family, household, and community with health facilities into dynamic health system to maintain continuum of services apart from integration of various reproductive and child health (RCH) interventions. To achieve uniformity and enhance quality of service data collection and its recording in terms of its accuracy and completeness instructions/footnotes have been provided and all the functionaries were trained. Durable maternal and child protection card (MCPC) retained by family/caregiver with pictorial action-oriented messages for behavior change communication now constitutes an integral part of IRCHR version 2.0. Village/Urban health sanitation and nutrition days (VHSND/UHSND) are held at the Anganwadi center to achieve convergence of services and data entries.
IRCHR adopts systems approach in reproductive and child health to convert inputs into processes/activities leading onto outputs resulting in effects and impacts of packages of service. IRCHR is thus a mirror of reproductive child health policies and programs. It is designed to collect village wise data for planning, monitoring, and evaluation of RCH services. Beneficiaries are tracked throughout their reproductive life span of 15–49 years, and thereafter, lifelong for expanded range of services for non-communicable diseases and care of the elderly people. Hopefully, the process of integration of records progressively continues to integrate the records of Rashtriya Kishor Swasthya Karyakaram, Human Papilloma Virus (HPV) vaccination to prevent and eliminate cancer cervix and screening for early detection of cervical cancer by visual inspection with acetic acid (VIA) and early detection of breast cancer as also oral cancer in women. Gestational diabetes and pregnancy-induced hypertension screening and management are already in place under the program.
The overall objective of this communication is to facilitate and stimulate the faculty of community medicine/community medicine and family medicine to use new IRCHR version 2.0 as learning resource material for UGs and PGs to develop competency of data collection and its analysis to generate information for action. The specific objective is to implement IRCHR in their field practice areas to develop various epidemiological studies especially cohort studies, case control studies, and interventional studies relevant to reproductive and child health programs besides operational research and health system research. This will help district and state to improve their programs. Further this instrument in combination with mother and child protection card having wealth of information on mother and baby cohort can be effectively used to learn varied aspects of almost all programs relevant to mother and child health in India. This approach enhances the teaching and training programs of community medicine in real life situation readily available and accessible to all medical colleges in the country.
CATCHMENT/COVERAGE AREA PROFILE
Essentially, coverage area profile of IRCHR indicates annual workload and resources available to carry out the activities of RCH program. IRCHR incorporates coverage area profile for rural and urban areas for two financial years. Area profile entry elaborates population of coverage area, total number of eligible couples, estimated number of pregnant women, estimated number of infants, and number of children between 1-2 years of age per year. It also incorporates available resources at sub health center and names and addresses of referral PHC/First Referral Unit (FRU).
Student is able to: Learn the concept of coverage of population by subcenter team and various target groups for integrated reproductive and child health services.
FIVE SECTIONS OF IRCHR VERSION 2.0
Section-A: Eligible couple/pregnant women registration and tracking of packages of service
It includes: eligible couples/pregnant women registration and infant details besides tracking of services of these target groups every month. Essentially, it tracks contraceptives acceptance, antenatal care, delivery, post-natal, and home-based neonatal care services apart from maternal, neonatal, infant, and adult deaths data and instructions for footnotes for eligible couples and pregnant women and infants to achieve uniformity of data collection and recording.
TRACKING OF ELIGIBLE COUPLES (EC) AND USE OF CONTRACEPTIVES
The information on number of EC is derived from regular annual household survey conducted by ASHA. There is built in system of mother and child tracking and all the eligible couples (married couples with age of wife between 15 and 49 years) throughout their reproductive span and beyond. All EC are contacted regularly once a month by home visits or as and when they report to subcenter clinic for service or gather on village/urban health sanitation and nutrition day once a month at Anganwadi center. EC data is updated by registration of all marriages and migrations. EC are segregated parity and age wise acceptors and non-acceptors of various methods of contraceptives. This helps ANM to prioritize target EC for spacing and permanent methods of family planning. New approach of method delivery is promotion of post-partum IUCD insertion within 24 hours of delivery by specially trained providers to tap opportunities offered by increased institutional deliveries (over 88% as of now) besides promotion of post abortion insertion of IUCD. Interval IUCD means insertion of IUCD after six weeks of delivery. An “Active” EC is one who is resident of the catchment area of ANM and is availing RCH services. An EC is termed as “Inactive” in case of permanent sterilization or migrated out or crossed the reproductive age of 49 years or lost to follow-up or has undergone hysterectomy. In case of male sterilization EC is considered as “Inactive” after 3 months and in case of female sterilization EC is considered as “inactive” after 1 month (after receiving certificate for sterilization from medical officer).
The student is able to learn the wide-ranging basket of contraceptives choice provided to EC, calculation of contraceptive prevalence rate, and couple protection rate from IRCHR data base to evaluate the impact of family welfare program. Person months of follow-up after IUCD insertion or condom use or use of oral/injectable contraceptives can be arrived to determine use effectiveness of contraceptives or Pearl Index apart from contraceptive failure rate to imbibe effective learning of design of a cohort study. The Pearl Index, a universal accepted measure of contraceptive efficacy, is the pregnancy rate per 100 women years of use of a given contraceptive method. The corrected Pearl Index can be calculated in the same manner but reflects only those pregnancies which are attributable to failure of contraceptive method used.
TRACKING OF PREGNANT WOMEN AND INFANTS FOR SERVICES
Early registration of pregnancy within 12 weeks of pregnancy helps women to opt out if pregnancy is unwanted. Pregnancy testing kits have been provided under the program to detect pregnancy at an early stage. Free of cost point of care tests such as repeated hemoglobin estimation, urine for sugar and albumin, blood glucose, universal HIV and Syphilis test, and measuring blood pressure, weight and height of pregnant mother are in place to detect high risk pregnant women for referral services. Service utilization data on packages of service of all pregnant women including outcomes of pregnancy are recorded in IRCHR and reported every month.
The student is able to learn:
(1) The packages of service provided to pregnant women, coverage level of pregnant women in the catchment area—the proportion of estimated pregnancies registered and proportion of registered pregnancies who received antenatal care per month, (2) Weight gain pattern of pregnant women in various trimesters as an example of design of cohort study, (3) The problem of anemia in pregnant, lactating women, and children, (4) The results of intervention of IFA supplementation, albendazole tablets, nutrition education for improvement of anemia by repeated testing of hemoglobin of pregnant women can be demonstrated to imbibe learning of interventional/experimental studies in epidemiology apart from case control studies, (5) Age of marriage, inter pregnancy interval, closed birth interval—interval between two successive births, open birth interval—interval between the last birth and date of study and total fertility rate at the end of 49 years of age of women can be derived from available data of IRCHR apart from other fertility indicators, and (6) The proportion of institutional and home deliveries and duration of institutional stay after delivery.
SECTION- B: CHILD REGISTRATION AND TRACKING OF SERVICES
It includes: month wise new children and low birth weight babies registered and tracking of services up to 6 years of age, home-based care of young children as also red flag signs on development delays for referrals apart from child mortality and instructions for footnotes for child services to achieve uniformity for data collection and recording.
TRACKING OF CHILD HEALTH SERVICES
Home-based essential newborn and post-natal care for each newborn and post-partum mother in the first six weeks as per defined schedule of 6-7 home visits by ASHA are recorded in IRCHR. These visits promote breast feeding and young child feeding practices at family level. Similarly, home-based care of young child by additional six visits with the support of Anganwadi workers (AWW) from 3 months of age onward up to 15 months of age ensures continuation of breast feeding, adequate complementary feeding, and food diversity as also age-appropriate immunization besides early childhood development. Data of these visits are recorded in the register along with appropriate actions by ASHA and AWW. Service Data on National Deworming Program and Anemia Mukt Bharat are also being recorded. Children are being followed up longitudinally for monitoring of growth and development and other interventions up to 6 years of age at subcenter/Anganwadi center, and thereafter, in schools under Rashtriya Bal Swasthya Karyakram (RBSK). This program aims at early interventions for birth defects, diseases, developmental delays, and deficiencies (4Ds) at the district early intervention center.
MOTHER AND CHILD PROTECTION CARD (MCPC)
MCPC has been prepared jointly by MoHFW and Ministry of Women and Child Development (MOWCD). The information contained in this durable card focuses on early childhood growth and development. It provides a continuum of care process that begins with planning for pregnancy and continued for at least the first two years of life. MoHFW earlier published a user-friendly resource on journey of the first thousand days of life for communication with pregnant women and caregivers. To make this information available with family and caregivers, the MCPC which targets pregnant women and the child till 3 years of age has been revised to include the information in an age appropriate pictorial description on child development. Age appropriate code for red flag signs (warning signs) of development delays are incorporated in MCPC for early recognition, referral, and management at district early intervention center. Thus, new MCPC is useful tool to assess developmental attainment of a child. The card now specifically includes information on what the child does by a specific age, what the parents should do to stimulate and engage with the child. Red flag sings on developmental issues have been coded in IRCHR for early referral of children with delayed milestones. This card provides information for growth monitoring of young children, early initiation of breast feeding, continuation of breast feeding till 2 years of age, and complementary feeding after 6 months of age along with breast feeding.
The student is able to learn:
(1) The packages of service provided to children, the proportion of low birth weight babies (preterm and small for gestational age babies) in the catchment area, (2) The growth pattern of young children in subcenter areas, (3) Weight gain pattern of young children during infancy and 1–5 years of age and developmental milestones at appropriate age by longitudinal follow-up of a child, (4) Prevalence of underweight, stunting, and wasting can be derived from growth monitoring records to learn epidemiology of Protein Energy Malnutrition and its management, (5) Interventional studies of therapeutic nutrition and disease intervention, (6) Month wise birth registration and registration of low birth weight babies helps to maintain a line list of births due for services under the RCH program. It helps to derive coverage levels of various services such as fully immunized children within 12 months of age and complete immunization within two years of age besides adverse events following immunization, and (7) Coverage level of growth monitoring, Vitamin A, IFA, and supplementary nutrition can be arrived month wise. Numerator for coverage evaluation is actual number of children provided service and denominator is all children due/eligible for a service in that month or a year.
SECTION-C: ASHA’S PERFORMANCE-BASED INCENTIVES FORMAT
It includes: ASHA gets incentives based on her performance. She records and reports month wise her incentive-based activities such as: follow-up of EC using injectable contraceptives under Antara Program, facilitating IUCD insertion, motivating beneficiaries for sterilization, ensuring spacing of two years after marriage, spacing of three years after birth of first child, opt for permanent/limiting methods after two children, family planning kit to newly weds (Nayi Pahel), facilitating antenatal care, institutional deliveries, post-natal visits at home, ensuring full immunization, complete immunization, motivating mothers for exclusive breast feeding for 6 months and initiating complementary feeding after 6 months, quarterly follow-up of low birth weight babies and newborns discharged from facility and follow-up of children with severe acute malnutrition (SAM) discharged from nutrition rehabilitation center, and reporting of births and deaths.
One can learn the role and responsibilities of ASHA at community level to promote community participation and facilitate accessing of health services for mother and child apart from home-based packages of RCH service provided by her.
SECTION-D: RECORDS OF LOGISTICS AND SUPPLY
It includes: monthly records of logistics for family planning items—stock received and utilized, details of each immunization session and its summary (antigen wise number of children and pregnant women besides Vitamin A doses).
The student is able to learn:
(1) Resources available to carry out RCH program, (2) Immunization sessions planned and actual number of sessions held, and (3) Coverage level of immunization
It includes age-appropriate codes for red flag signs on developmental issues, national immunization schedule of 2022, types of area (rural and urban hierarchy), and calendar for expected date of delivery and AADHAR consent form.
The student is able to learn:
Developmental delays in children, universal immunization program, and national immunization schedule and calculation of expected date of delivery.
Service data base of IRCHR is a ready reckoner for UGs and PGs as it integrates all high impact interventions that improve maternal and child health and their nutritional status. Data base of this register for various reproductive, maternal, newborn, and child health plus adolescent health (RMCNH + A) services can be used as a learning resource material to achieve various competencies. By implementation of IRCHR in the field practice area of respective Medical College ensures its involvement and participation at least in 12 national health programs such as National Family Welfare Program, National Population Policy, Janani Suraksha Yojna, Janani Shishu Suraksha Karyakram, Pradhan Mantri Surakshit Matritva Abhiyaan, Anemia Mukt Bharat, India’s newborn action plan, Homebased newborn and young child care, Integrated management of newborn and child illness especially pneumonia and diarrhea, Universal Immunization Program, Integrated Child Development Services (ICDS), National Deworming Program, and Rashtriya Bal Swasthya Karyakram and Medical Termination of Pregnancy to name a few. Mother and Child Protection card is an excellent tool of home-based/family-retained record for behavior change communication as it provides integrated information, education, and communication pictorial action-oriented messages in local language. Monitoring performance indicators on maternal and child health services can be learned from IRCHR data base and compared with standard performance to determine the performance gap. Root causes of these gaps (bottlenecks) can be analyzed to effect improvement in performance gaps.