Abstract

The National Rural Health Mission (NRHM), launched by the Government of India in April 2005, aimed to strengthen the rural public health system with a particular emphasis on reducing maternal and infant mortality. The Mission sought to improve access, affordability and quality of healthcare through increased public investment, decentralization, community participation and health system strengthening. This working paper reviews the progress of Maternal and Child Health (MCH) services under NRHM from its inception up to 2012. It examines key interventions, available evidence, achievements and persistent challenges based solely on information available up to 2012.

 

1. Introduction

Maternal and child health has remained one of India's foremost public health priorities. At the beginning of the Eleventh Five-Year Plan, India accounted for a significant share of global maternal and child deaths. Rural populations, particularly in economically weaker states, faced limited access to skilled birth attendance, emergency obstetric care and essential newborn services.

Recognizing these challenges, the Government of India launched the National Rural Health Mission (NRHM) on 12 April 2005 to improve healthcare delivery in rural areas, especially in eighteen high-focus states characterized by weak health indicators and inadequate infrastructure.

The Mission integrated existing health programmes and strengthened primary healthcare through community participation and decentralized planning.

 

2. Objectives of NRHM

The principal objectives relating to maternal and child health included:

• Reduction of Maternal Mortality Ratio (MMR).

• Reduction of Infant Mortality Rate (IMR).

• Universal access to antenatal care.

• Skilled attendance during childbirth.

• Increased institutional deliveries.

• Universal immunization.

• Improved nutrition and newborn care.

• Strengthening referral and emergency obstetric services.

• Community ownership of public health services.

 

3. Maternal Health Interventions under NRHM

3.1 Janani Suraksha Yojana (JSY)

Janani Suraksha Yojana (JSY) was launched by the Government of India on 12 April 2005 under the National Rural Health Mission (NRHM). It was designed as a safe motherhood intervention to reduce maternal and neonatal mortality by promoting institutional deliveries among poor pregnant women. JSY is a centrally sponsored scheme that integrates cash assistance with maternal healthcare services, making it one of the largest conditional cash transfer programmes for maternal health in the world.

Before the introduction of JSY, a large proportion of births in India, particularly in rural and economically disadvantaged areas, occurred at home without the assistance of skilled health personnel. Such deliveries were associated with a higher risk of complications, maternal deaths, and neonatal mortality. JSY sought to address these challenges by reducing financial barriers to accessing institutional delivery services.

Objectives

The primary objectives of Janani Suraksha Yojana were to:

• Increase institutional deliveries by encouraging pregnant women to deliver in public health facilities or accredited private institutions.

• Reduce Maternal Mortality Ratio (MMR) by ensuring access to skilled birth attendants and emergency obstetric care.

• Reduce neonatal mortality through safe delivery practices and immediate newborn care.

• Improve access to maternal health services among women belonging to Below Poverty Line (BPL) households, Scheduled Castes (SC), Scheduled Tribes (ST), and other vulnerable groups.

• Promote antenatal care, institutional delivery, and postnatal care through community mobilization and support.

Key Features

JSY provides cash incentives to eligible pregnant women who deliver in health institutions. The amount of assistance varies according to the classification of states as Low Performing States (LPS) and High Performing States (HPS), reflecting differences in institutional delivery rates and maternal health indicators.

The scheme also provides performance-based incentives to Accredited Social Health Activists (ASHAs) for identifying pregnant women, facilitating antenatal care, accompanying them to health facilities for delivery, and ensuring postnatal follow-up. This community-based approach helped bridge the gap between rural communities and public health facilities.

Implementation Strategy

The implementation of JSY relied on strengthening the existing public health infrastructure under NRHM. Pregnant women were encouraged to register their pregnancies early, attend antenatal check-ups, receive tetanus immunization and iron-folic acid supplementation, and opt for institutional delivery.

ASHAs played a pivotal role by:

• Identifying and registering pregnant women.

• Creating awareness regarding safe motherhood practices.

• Facilitating antenatal care visits.

• Arranging transportation to health facilities.

• Accompanying women during institutional delivery.

• Promoting postnatal care and newborn immunization.

The scheme worked in coordination with Sub-Centres, Primary Health Centres (PHCs), Community Health Centres (CHCs), and District Hospitals to improve the availability of maternal health services.

Achievements

Between 2005 and 2012, JSY significantly transformed maternal healthcare utilization in India. Institutional deliveries increased substantially, particularly in rural areas and high-focus states covered under NRHM. Millions of pregnant women received financial assistance each year, reducing the economic burden associated with childbirth.

The programme also contributed to greater utilization of antenatal and postnatal services, improved community awareness regarding safe delivery practices, and increased interaction between pregnant women and public health facilities. The widespread deployment of ASHAs strengthened community outreach and encouraged timely referral of high-risk pregnancies.

Evidence available up to 2012 indicated that the expansion of institutional deliveries under JSY contributed to the decline in India's Maternal Mortality Ratio and Infant Mortality Rate observed during the period, although improvements also reflected broader health system strengthening under NRHM.

Challenges

Despite its considerable achievements, JSY faced several implementation challenges up to 2012:

• Quality of care in many public health facilities did not improve at the same pace as the increase in institutional deliveries.

• Shortages of skilled doctors, nurses, and specialists persisted, particularly in rural and remote areas.

• Delays in disbursement of cash incentives were reported in some states.

• Emergency obstetric care and referral transport services remained inadequate in several districts.

• Variations in programme performance across states reflected differences in health infrastructure, administrative capacity, and availability of human resources.

By 2012, Janani Suraksha Yojana had emerged as one of India's most significant maternal health interventions. By combining financial incentives with community mobilization and expanded access to institutional delivery services, the scheme substantially increased the use of skilled birth care among poor and rural women. While challenges related to quality of care and health system capacity remained, JSY played a central role in advancing the maternal health objectives of the National Rural Health Mission and laid the foundation for subsequent maternal and child health initiatives in India.

 

 3.2 Accredited Social Health Activist (ASHA)

The Accredited Social Health Activist (ASHA) programme was introduced under the National Rural Health Mission (NRHM) in 2005 as a key strategy to strengthen community participation in the public health system. Recognizing the shortage of healthcare personnel and the limited accessibility of health services in rural India, NRHM envisioned ASHA as a trained female community health volunteer who would act as a link between the community and the public health system.

Each ASHA was generally selected from the village in which she resided, ensuring that she was familiar with the local population, culture, and health needs. As a resident of the community, she was expected to promote health awareness, facilitate access to healthcare services, and mobilize community participation in health programmes. Rather than serving as a salaried government employee, ASHAs received performance-based incentives linked to specific health activities, particularly maternal and child health services.

Objectives

The ASHA programme was designed to achieve the following objectives:

• Improve access to essential healthcare services in rural areas.

• Promote maternal and child health through community-based interventions.

• Increase awareness regarding preventive and promotive healthcare.

• Facilitate utilization of public health facilities.

• Strengthen community participation in health planning and service delivery.

• Reduce maternal, neonatal, and infant mortality through timely healthcare interventions.

Roles and Responsibilities

ASHA workers performed a wide range of activities aimed at improving maternal and child health outcomes.

Early Registration of Pregnancy

One of the primary responsibilities of ASHAs was to identify pregnant women at the earliest stage and encourage timely registration of pregnancy. Early registration enabled women to receive regular antenatal care, nutritional counselling, and essential preventive services throughout pregnancy.

Promotion of Antenatal Care

ASHAs encouraged pregnant women to attend scheduled antenatal check-ups at Sub-Centres, Primary Health Centres (PHCs), or other public health facilities. They educated women about the importance of tetanus toxoid immunization, iron and folic acid supplementation, adequate nutrition, birth preparedness, and recognition of danger signs during pregnancy.

Encouraging Institutional Delivery

Institutional delivery was one of the major priorities under NRHM. ASHAs motivated pregnant women and their families to opt for delivery at public health institutions or accredited facilities where skilled birth attendants and emergency obstetric care were available. They also assisted women in accessing benefits under the Janani Suraksha Yojana (JSY) and, where available, arranged transportation to health facilities.

Promotion of Immunization

ASHAs played an important role in strengthening the Universal Immunization Programme. They mobilized parents to ensure that pregnant women received tetanus immunization and that newborns and children completed the recommended immunization schedule. Their community-level outreach contributed to improved immunization coverage in many rural areas.

Home Visits After Delivery

Postnatal home visits formed an essential component of ASHA's responsibilities. During these visits, ASHAs monitored the health of both mother and newborn, promoted exclusive breastfeeding, advised on newborn care and hygiene, identified early signs of complications, and referred cases requiring medical attention to appropriate health facilities.

Health Education and Community Mobilization

ASHAs served as health educators within their communities. They disseminated information on nutrition, sanitation, family planning, safe drinking water, communicable disease prevention, child care, and healthy lifestyle practices. They also encouraged participation in Village Health and Nutrition Days and supported Village Health and Sanitation Committees in community health planning.

Contribution to Maternal and Child Health

The ASHA programme significantly strengthened the implementation of maternal and child health interventions under NRHM. By providing continuous support throughout pregnancy, childbirth, and the postnatal period, ASHAs improved awareness and utilization of maternal health services. Their close interaction with families increased the uptake of antenatal care, institutional deliveries, immunization services, and newborn care practices.

The programme also helped improve communication between rural communities and public health institutions, particularly among disadvantaged populations that previously had limited contact with formal healthcare services.

Progress up to 2012

By 2012, the ASHA programme had become one of the largest community health worker initiatives in the world. According to National Rural Health Mission (NRHM) estimates, approximately 850,000 ASHAs had been selected and deployed across rural India. Their presence extended to nearly every village, making them the primary point of contact between households and the public health system.

The large-scale deployment of ASHAs contributed to increased institutional deliveries, improved immunization coverage, greater utilization of antenatal and postnatal care services, and enhanced community awareness regarding maternal and child health. The programme was widely recognized as a cornerstone of NRHM's strategy to improve rural health outcomes.

Challenges

Despite its achievements, the ASHA programme faced several challenges up to 2012. Variations existed in the quality and duration of training across states. Delays in the payment of performance-based incentives affected worker motivation in some areas. Many ASHAs also faced heavy workloads, inadequate supervision, and limited opportunities for skill development. Furthermore, weak health infrastructure in certain regions constrained their ability to refer beneficiaries and ensure continuity of care.

Up to 2012, the Accredited Social Health Activist (ASHA) programme emerged as one of the most significant innovations of the National Rural Health Mission. By serving as a trusted community health volunteer, the ASHA bridged the gap between rural households and public health facilities. Her contribution to early pregnancy registration, antenatal care, institutional delivery, immunization, postnatal care, and health education played a vital role in improving maternal and child health service utilization across rural India and contributed substantially to the objectives of NRHM.

 

3.3 Antenatal Care under the National Rural Health Mission (NRHM)

Antenatal Care (ANC) is a critical component of maternal healthcare, aimed at ensuring the health and well-being of both the mother and the developing fetus throughout pregnancy. Regular antenatal care facilitates the early detection and management of pregnancy-related complications, provides preventive healthcare services, and prepares women for safe childbirth. Recognizing the importance of antenatal care in reducing maternal and neonatal morbidity and mortality, the National Rural Health Mission (NRHM), launched in 2005, placed considerable emphasis on expanding the coverage and quality of antenatal services in rural India.

Before the implementation of NRHM, many pregnant women in rural areas either registered late for antenatal care or did not receive the recommended number of antenatal check-ups due to limited awareness, financial constraints, poor accessibility to health facilities, and shortages of healthcare personnel. NRHM sought to address these barriers by strengthening service delivery through Sub-Centres, Primary Health Centres (PHCs), Community Health Centres (CHCs), and community-based health workers such as Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs).

Objectives

The antenatal care component of NRHM aimed to:

• Ensure early registration of pregnancy.

• Provide regular antenatal examinations throughout pregnancy.

• Detect and manage high-risk pregnancies.

• Prevent maternal anaemia through Iron and Folic Acid (IFA) supplementation.

• Protect mothers and newborns against neonatal tetanus through tetanus immunization.

• Promote healthy pregnancy practices through counselling and health education.

• Improve maternal and neonatal outcomes by facilitating timely referral and institutional delivery.

Key Components of Antenatal Care

Early Registration of Pregnancy

NRHM encouraged women to register their pregnancies as early as possible, preferably during the first trimester. Early registration enabled healthcare providers to monitor pregnancy from its initial stages, estimate the expected date of delivery, identify risk factors, and ensure that women received essential maternal health services throughout pregnancy. ASHAs and ANMs played an important role in identifying pregnant women within the community and facilitating their registration at public health facilities.

Minimum Three Antenatal Check-ups

According to the prevailing Government of India recommendations up to 2012, every pregnant woman was expected to receive at least three antenatal check-ups during pregnancy. These visits generally included:

• Measurement of weight and blood pressure.

• Abdominal examination to assess fetal growth and position.

• Screening for pregnancy-related complications.

• Monitoring of maternal health.

• Counselling regarding nutrition, hygiene, birth preparedness, and danger signs.

Regular antenatal visits enabled early detection of conditions such as pregnancy-induced hypertension, severe anaemia, infections, and other complications requiring specialized care.

Iron and Folic Acid Supplementation

Maternal anaemia remained a major public health problem in India and was an important contributor to maternal mortality, preterm births, and low birth weight. To address this issue, NRHM strengthened the provision of Iron and Folic Acid (IFA) tablets to pregnant women through public health facilities.

Pregnant women were advised to consume IFA tablets for the prevention and treatment of anaemia. ASHAs and ANMs counselled women regarding the importance of compliance with supplementation and monitored its use during home visits and antenatal sessions.

Tetanus Immunization

NRHM ensured that pregnant women received Tetanus Toxoid (TT) immunization as part of routine antenatal care. Tetanus immunization protected both mothers and newborns against maternal and neonatal tetanus, a serious but preventable cause of mortality. Vaccination services were provided through outreach sessions, Sub-Centres, Primary Health Centres, and immunization clinics.

Identification of High-Risk Pregnancies

A major objective of antenatal care under NRHM was the early identification of women with high-risk pregnancies. Healthcare providers screened pregnant women for conditions such as:

• Severe anaemia.

• High blood pressure and pre-eclampsia.

• Gestational diabetes (where diagnostic facilities were available).

• Multiple pregnancies.

• Abnormal fetal presentation.

• Previous obstetric complications.

• Maternal age-related risks and other medical disorders.

Women identified with high-risk pregnancies were referred to higher-level health facilities for specialized care and safe delivery planning.

Role of Community Health Workers

Accredited Social Health Activists (ASHAs) and Auxiliary Nurse Midwives (ANMs) played a central role in the successful implementation of antenatal care services under NRHM. They promoted early registration of pregnancy, mobilized women for antenatal check-ups, distributed Iron and Folic Acid tablets, encouraged tetanus immunization, provided health education, and facilitated referral of high-risk cases to appropriate health facilities.

Achievements up to 2012

Between 2005 and 2012, NRHM substantially improved the utilization of antenatal care services in rural India. Increased community awareness, strengthened primary healthcare infrastructure, and the active involvement of ASHAs and ANMs contributed to higher rates of pregnancy registration and antenatal visits. The programme also improved the availability of Iron and Folic Acid supplementation and tetanus immunization through public health facilities.

Although considerable progress was made, challenges remained in ensuring universal coverage, particularly in remote and underserved regions. Variations in service quality, shortages of trained healthcare personnel, and inconsistent availability of medicines and diagnostic facilities continued to affect programme effectiveness.

Antenatal care under the National Rural Health Mission represented a comprehensive strategy to improve maternal health by ensuring early pregnancy registration, regular health check-ups, nutritional supplementation, immunization, and timely identification of high-risk pregnancies. By strengthening community outreach and expanding access to essential maternal health services, NRHM contributed significantly to improving maternal and newborn health outcomes in rural India up to 2012. However, sustained efforts to improve service quality, infrastructure, and human resources remained essential for achieving universal access to quality antenatal care.

 

3.4 Skilled Birth Attendance under the National Rural Health Mission (NRHM)

Skilled Birth Attendance (SBA) is recognized as one of the most effective interventions for reducing maternal and neonatal mortality. A Skilled Birth Attendant is an accredited health professional—such as a doctor, staff nurse, or Auxiliary Nurse Midwife (ANM)—who has been trained to manage normal pregnancies and childbirth, recognize complications, and initiate appropriate interventions or referrals when required.

Before the launch of the National Rural Health Mission (NRHM) in 2005, a large proportion of deliveries in rural India were conducted at home by untrained or inadequately trained birth attendants. Limited availability of skilled health personnel, inadequate infrastructure, and poor referral systems contributed to preventable maternal and neonatal deaths. To address these challenges, NRHM prioritized the expansion of skilled birth attendance as a central strategy for ensuring safe motherhood and improving newborn survival.

Objectives

The Skilled Birth Attendance component of NRHM aimed to:

• Ensure that every pregnant woman had access to a trained health professional during childbirth.

• Reduce maternal and neonatal mortality through safe delivery practices.

• Improve the quality of obstetric care in public health facilities.

• Strengthen emergency management of obstetric complications.

• Increase institutional deliveries supported by skilled personnel.

Key Components

Training of Skilled Birth Attendants

One of the major initiatives under NRHM was the large-scale training of healthcare providers in Skilled Birth Attendance (SBA). Medical officers, staff nurses, and Auxiliary Nurse Midwives (ANMs) received standardized training in evidence-based practices for normal delivery, infection prevention, active management of the third stage of labour, newborn resuscitation, identification of danger signs, and timely referral of complicated cases.

The objective was to ensure that deliveries conducted at public health facilities met minimum standards of safety and quality and that complications such as postpartum haemorrhage, obstructed labour, and eclampsia were recognized and managed promptly.

Strengthening Labour Rooms

NRHM invested in improving labour room infrastructure at Sub-District Hospitals, Community Health Centres (CHCs), Primary Health Centres (PHCs), and District Hospitals. Labour rooms were upgraded with essential equipment, delivery tables, sterilization facilities, emergency medicines, newborn care equipment, and infection control measures.

The strengthening of labour rooms aimed to create a safe environment for childbirth and improve the quality of intrapartum care. Better-equipped facilities also enabled healthcare providers to manage common obstetric emergencies before referring patients to higher-level institutions when necessary.

Increasing Availability of Auxiliary Nurse Midwives (ANMs)

Auxiliary Nurse Midwives (ANMs) formed the backbone of maternal and child health services at the village and sub-centre levels. NRHM expanded the recruitment and deployment of ANMs to improve access to skilled care in rural and underserved areas. Additional ANMs were appointed in many states to strengthen antenatal care, conduct normal deliveries where appropriate, provide postnatal care, and support immunization and family welfare services.

By increasing the availability of ANMs, NRHM sought to ensure that pregnant women had greater access to qualified health personnel, particularly in remote villages where medical officers and specialists were scarce.

Deployment of Staff Nurses

Recognizing the shortage of trained nursing personnel in public health facilities, NRHM supported the recruitment of contractual and regular staff nurses, particularly at Primary Health Centres, Community Health Centres, First Referral Units (FRUs), and District Hospitals. Staff nurses played a vital role in providing round-the-clock delivery services, monitoring labour, assisting in emergency obstetric care, caring for newborns, and maintaining infection prevention standards.

The deployment of additional staff nurses helped improve the availability of skilled birth attendants at health facilities and facilitated the implementation of 24×7 delivery services in many public institutions.

Contribution to Maternal and Newborn Health

The emphasis on skilled birth attendance under NRHM significantly contributed to improving the quality and safety of childbirth services. The presence of trained healthcare providers during labour enabled early identification and management of complications, timely referral to higher-level facilities, and appropriate care for newborns immediately after birth.

These interventions complemented other NRHM initiatives, such as the Janani Suraksha Yojana (JSY), which encouraged institutional deliveries, and the ASHA programme, which mobilized pregnant women to seek skilled care during childbirth.

Progress up to 2012

Between 2005 and 2012, NRHM substantially expanded the availability of skilled birth attendants across rural India. Thousands of ANMs, staff nurses, and medical officers received SBA training, while many public health facilities strengthened their labour rooms and introduced round-the-clock delivery services. These measures contributed to a marked increase in institutional deliveries and supported the observed decline in maternal and infant mortality during this period.

Despite these achievements, challenges persisted. Many rural health facilities continued to face shortages of specialists, uneven distribution of trained personnel, inadequate infrastructure, and limited emergency obstetric services. Ensuring the quality of care remained an important concern even as the number of institutional deliveries increased.

Skilled Birth Attendance emerged as one of the cornerstone interventions of the National Rural Health Mission for improving maternal and newborn health. Through the training of healthcare providers, strengthening of labour rooms, expansion of the ANM workforce, and deployment of additional staff nurses, NRHM improved access to skilled care during childbirth in rural India. Although gaps in infrastructure and human resources remained, these efforts significantly enhanced the capacity of the public health system to provide safer deliveries and contributed to the Mission's broader objective of reducing maternal and neonatal mortality up to 2012.

 

3.5 Emergency Obstetric Care under the National Rural Health Mission (NRHM)

Emergency Obstetric Care (EmOC) is a critical component of maternal healthcare that aims to prevent maternal and neonatal deaths resulting from complications during pregnancy, labour, childbirth, and the immediate postpartum period. Although most pregnancies progress normally, approximately 15 percent of pregnant women may develop life-threatening obstetric complications requiring immediate medical intervention. The major causes of maternal mortality include postpartum haemorrhage, obstructed labour, hypertensive disorders such as eclampsia, sepsis, and complications related to unsafe abortions.

Prior to the launch of the National Rural Health Mission (NRHM) in April 2005, access to emergency obstetric services in rural India was limited. Many Community Health Centres (CHCs) lacked specialists, operation theatres, blood storage facilities, and essential equipment. Referral mechanisms were weak, and delays in obtaining appropriate medical care contributed significantly to maternal mortality. To address these deficiencies, NRHM identified Emergency Obstetric Care as a priority area for strengthening the rural health system.

Objectives

The Emergency Obstetric Care strategy under NRHM sought to:

• Reduce maternal mortality arising from obstetric emergencies.

• Ensure timely access to comprehensive emergency obstetric services.

• Strengthen referral institutions capable of managing complicated pregnancies and deliveries.

• Improve the availability of emergency surgical and blood transfusion services.

• Reduce delays in transporting pregnant women requiring emergency care.

• Enhance the capacity of public health facilities to provide quality maternal healthcare.

Upgrading Community Health Centres (CHCs)

Community Health Centres serve as the first level of specialist healthcare in rural India. Under NRHM, considerable efforts were made to upgrade CHCs in accordance with the Indian Public Health Standards (IPHS) issued in 2007. These standards prescribed infrastructure, manpower, equipment, medicines, and service delivery norms required for providing quality healthcare.

The upgrading of CHCs included:

• Renovation and modernization of labour rooms.

• Establishment of functional operation theatres.

• Provision of essential obstetric and neonatal equipment.

• Availability of emergency drugs and consumables.

• Strengthening infection prevention and sterilization practices.

• Ensuring twenty-four-hour delivery services wherever feasible.

Improved CHCs were expected to manage normal deliveries, stabilize obstetric emergencies, perform selected emergency procedures, and refer complicated cases to higher-level facilities when necessary.

Strengthening First Referral Units (FRUs)

First Referral Units (FRUs) constituted the most important component of Emergency Obstetric Care under NRHM. Selected Community Health Centres, Sub-District Hospitals, and District Hospitals were upgraded to function as FRUs capable of managing severe obstetric and newborn complications.

According to Government of India guidelines, a fully functional FRU was expected to provide:

• Twenty-four-hour delivery services.

• Comprehensive emergency obstetric care.

• Caesarean section facilities.

• Anaesthesia services.

• Blood storage facilities.

• Newborn care and neonatal resuscitation.

• Management of obstetric emergencies such as postpartum haemorrhage, obstructed labour, eclampsia, septic shock, and retained placenta.

Strengthening FRUs involved infrastructure development, recruitment of specialists, procurement of medical equipment, and provision of emergency medicines.

Blood Storage Units

Severe obstetric haemorrhage remained one of the leading causes of maternal deaths in India. Since blood transfusion is often life-saving in such situations, NRHM promoted the establishment of Blood Storage Units (BSUs) at designated First Referral Units.

Blood Storage Units were intended to:

• Maintain adequate stocks of screened blood.

• Facilitate timely blood transfusion during obstetric emergencies.

• Improve management of postpartum haemorrhage.

• Reduce deaths caused by severe anaemia and excessive blood loss during childbirth.

These units functioned under the technical supervision of licensed blood banks and expanded access to emergency blood transfusion services in rural areas where full-fledged blood banks were unavailable.

Referral Transport Services

One of the major reasons for maternal mortality in rural India was the delay in reaching an appropriate healthcare facility after the onset of obstetric complications. Recognizing this problem, NRHM encouraged states to develop referral transport systems to facilitate rapid transportation of pregnant women.

Several states introduced:

• Ambulance services.

• Emergency transport vehicles.

• Public-private partnership models for referral transport.

• District-level transport networks linking villages with PHCs, CHCs, and District Hospitals.

Although the national ambulance service (108) was implemented later in many states, by 2012 several states had already developed state-specific emergency transport mechanisms under NRHM support.

Improved referral transport reduced delays in accessing institutional care and contributed to increased utilization of emergency obstetric services.

Human Resource Strengthening

Infrastructure alone was insufficient without trained personnel. NRHM therefore focused on improving the availability of skilled human resources by:

• Recruiting obstetricians on contractual appointments where possible.

• Training medical officers in Life Saving Anaesthetic Skills (LSAS).

• Training MBBS doctors in Emergency Obstetric Care (EmOC).

• Recruiting and deploying additional staff nurses.

• Expanding the number of Auxiliary Nurse Midwives (ANMs).

• Training Skilled Birth Attendants (SBAs).

These measures sought to improve the availability of emergency obstetric services, particularly in underserved rural districts.

Linkages with Other NRHM Interventions

Emergency Obstetric Care was closely integrated with other maternal health initiatives under NRHM.

• Janani Suraksha Yojana (JSY) encouraged pregnant women to deliver in institutions where emergency obstetric care was available.

• Accredited Social Health Activists (ASHAs) identified pregnant women, promoted institutional deliveries, recognized danger signs during pregnancy, and facilitated timely referral.

• Strengthened antenatal care enabled early identification of high-risk pregnancies requiring institutional management.

• Facility-based newborn care improved survival of newborns delivered following complicated pregnancies.

Together, these interventions formed an integrated continuum of maternal and newborn care.

Progress up to 2012

Between 2005 and 2012, NRHM made substantial investments in strengthening Emergency Obstetric Care across rural India.

Major achievements included:

• Upgradation of numerous Community Health Centres and District Hospitals.

• Operationalization of additional First Referral Units.

• Establishment of Blood Storage Units in selected facilities.

• Expansion of twenty-four-hour delivery services.

• Increased availability of Skilled Birth Attendants and staff nurses.

• Introduction of referral transport services in many states.

• Improved utilization of institutional delivery services.

These improvements complemented the rapid expansion of institutional deliveries under Janani Suraksha Yojana and contributed to the decline in maternal mortality observed during this period. According to the Sample Registration System (SRS), India's Maternal Mortality Ratio declined from 254 per 100,000 live births (2004–06) to 212 per 100,000 live births (2007–09).

Challenges

Despite considerable progress, several challenges remained up to 2012.

Many First Referral Units could not function as comprehensive emergency obstetric care centres because of shortages of obstetricians, anaesthetists, and paediatricians. Infrastructure improvements were often not matched by adequate human resources. Blood Storage Units remained non-functional in some districts due to licensing issues, irregular blood supply, or lack of trained personnel.

Referral transport services were unevenly developed across states, particularly in remote and tribal areas where poor road connectivity delayed access to healthcare. Maintenance of medical equipment, uninterrupted electricity, and water supply also affected service quality in several facilities.

Furthermore, while institutional deliveries increased significantly, ensuring consistent quality of emergency obstetric care remained a major challenge.

Emergency Obstetric Care emerged as one of the most important components of the National Rural Health Mission's strategy to reduce maternal mortality in rural India. By upgrading Community Health Centres, strengthening First Referral Units, establishing Blood Storage Units, improving referral transport, and enhancing the availability of trained health personnel, NRHM substantially improved the capacity of the public health system to manage obstetric emergencies.

Although important gains were achieved between 2005 and 2012, further strengthening of specialist human resources, referral systems, blood transfusion services, and quality of care remained essential to ensure universal access to comprehensive emergency obstetric services and sustain reductions in maternal mortality.

 

4. Child Health Interventions

4.1 Universal Immunization Programme (UIP) under the National Rural Health Mission (NRHM)

The Universal Immunization Programme (UIP) is one of India's flagship public health programmes aimed at protecting infants, children, and pregnant women against vaccine-preventable diseases. The programme was launched as the Expanded Programme on Immunization (EPI) in 1978 and was upgraded to the Universal Immunization Programme (UIP) in 1985. In 1992, UIP became an integral component of the Child Survival and Safe Motherhood (CSSM) Programme and later the Reproductive and Child Health (RCH) Programme. With the launch of the National Rural Health Mission (NRHM) in April 2005, strengthening routine immunization became one of the Mission's key priorities for improving child survival and reducing infant and under-five mortality.

Despite decades of implementation, immunization coverage in India remained inadequate before NRHM. The National Family Health Survey (NFHS-3, 2005–06) reported that only 43.5 percent of children aged 12–23 months were fully immunized, with considerable disparities across states, socio-economic groups, and rural-urban populations. Inadequate health infrastructure, irregular vaccine supply, weak cold chain systems, shortage of trained health workers, and low community awareness were among the major barriers to achieving universal immunization coverage.

Recognizing these challenges, NRHM adopted a comprehensive approach to strengthen routine immunization services by improving health infrastructure, ensuring vaccine availability, strengthening logistics, and mobilizing communities to increase demand for immunization services.

Objectives

The Universal Immunization Programme under NRHM aimed to:

• Provide universal access to life-saving vaccines for all eligible children and pregnant women.

• Reduce infant and under-five mortality due to vaccine-preventable diseases.

• Eliminate neonatal tetanus through immunization of pregnant women.

• Strengthen routine immunization services in rural and underserved areas.

• Improve equity in access to immunization services.

• Increase community awareness regarding the importance of complete immunization.

Strengthening Vaccine Availability

A major focus of NRHM was ensuring the uninterrupted availability of vaccines throughout the public health system. Prior to NRHM, many health facilities experienced periodic shortages of vaccines, resulting in missed immunization opportunities.

To address this issue, NRHM strengthened vaccine procurement, storage, and distribution systems across states. Vaccines were supplied regularly to District Hospitals, Community Health Centres (CHCs), Primary Health Centres (PHCs), and Sub-Centres to ensure that immunization sessions could be conducted without interruption. Improved logistics management and monitoring reduced vaccine stock-outs and enabled better planning of routine immunization activities.

Cold Chain Maintenance

Vaccines remain effective only when stored and transported within prescribed temperature ranges. Any break in the cold chain can reduce vaccine potency and compromise the effectiveness of immunization programmes.

Under NRHM, considerable investments were made to strengthen the cold chain infrastructure. This included procurement and maintenance of Ice-Lined Refrigerators (ILRs), Deep Freezers, cold boxes, vaccine carriers, and temperature monitoring devices at various levels of the public health system. Health personnel received training in vaccine storage, handling, transportation, and temperature monitoring to ensure vaccine quality.

Strengthening the cold chain improved the reliability of immunization services and reduced vaccine wastage, particularly in remote rural areas.

Outreach Sessions

To improve access for populations living in villages distant from health facilities, NRHM expanded the number of routine outreach immunization sessions. Auxiliary Nurse Midwives (ANMs) conducted vaccination sessions at Anganwadi Centres, schools, village health centres, and other community locations.

Village Health and Nutrition Days (VHNDs), organized jointly by the Health Department and the Integrated Child Development Services (ICDS), became important platforms for delivering immunization services alongside antenatal care, nutrition counselling, growth monitoring, and health education. These outreach activities significantly increased the reach of routine immunization, particularly among marginalized and hard-to-reach populations.

Community Mobilization

Community participation was recognized as essential for improving immunization coverage. Under NRHM, Accredited Social Health Activists (ASHAs), Auxiliary Nurse Midwives (ANMs), and Anganwadi Workers (AWWs) worked together to identify eligible children and pregnant women, educate families about the benefits of vaccination, and encourage attendance at immunization sessions.

ASHAs conducted household visits, prepared lists of children due for vaccination, reminded parents about scheduled immunization sessions, and followed up with children who missed vaccine doses. Community awareness campaigns, interpersonal communication, and village meetings helped address misconceptions regarding vaccines and improved acceptance of routine immunization services.

Progress up to 2012

The strengthening of routine immunization under NRHM led to measurable improvements in immunization coverage. According to the Coverage Evaluation Survey (CES), 2009, approximately 61 percent of children aged 12–23 months were fully immunized, representing a substantial improvement over the 43.5 percent reported in the National Family Health Survey (NFHS-3, 2005–06).

The programme also contributed to increased coverage of individual vaccines such as BCG, DPT, Oral Polio Vaccine (OPV), and Measles in many states. High-focus states, where NRHM investments were concentrated, recorded improvements in routine immunization through enhanced outreach, better infrastructure, and stronger community mobilization.

India also achieved a significant milestone in polio control during this period, reporting its last case of wild poliovirus in January 2011, reflecting the combined success of routine immunization and supplementary polio immunization activities.

Challenges

Despite significant progress, several challenges persisted up to 2012. Immunization coverage continued to vary considerably across states and districts, with lower coverage in tribal, remote, and underserved areas. Weak health infrastructure, shortages of trained personnel, vaccine stock-outs in certain locations, and interruptions in cold chain maintenance occasionally affected programme implementation.

Socio-cultural barriers, low parental awareness, and misconceptions regarding vaccination also contributed to incomplete immunization among some communities. Ensuring that children completed the full immunization schedule remained an operational challenge requiring continuous community engagement and effective monitoring.

Under the National Rural Health Mission, the Universal Immunization Programme underwent significant strengthening through improved vaccine availability, enhanced cold chain infrastructure, expansion of outreach services, and active community mobilization. These interventions increased access to immunization services, particularly in rural and underserved areas, and contributed to higher vaccination coverage. The improvement in full immunization coverage from 43.5 percent (NFHS-3) to approximately 61 percent (Coverage Evaluation Survey, 2009) demonstrated the positive impact of NRHM initiatives. Although regional disparities and operational challenges remained, the programme established a stronger foundation for reducing vaccine-preventable diseases and improving child survival in India up to 2012.

 

4.2 Integrated Management of Neonatal and Childhood Illness (IMNCI)

The Integrated Management of Neonatal and Childhood Illness (IMNCI) is a comprehensive child survival strategy adopted by the Government of India to reduce neonatal and under-five mortality through an integrated approach to the prevention and management of common childhood illnesses. IMNCI is the Indian adaptation of the Integrated Management of Childhood Illness (IMCI) strategy developed jointly by the World Health Organization (WHO) and the United Nations Children's Fund (UNICEF). Unlike the original IMCI strategy, the Indian adaptation places greater emphasis on the neonatal period, as neonatal deaths accounted for nearly two-thirds of infant deaths in India.

The IMNCI strategy was introduced in India in 2003–04 and was subsequently integrated into the National Rural Health Mission (NRHM) after its launch in 2005. Under NRHM, IMNCI became one of the key interventions for improving child survival by strengthening the capacity of health workers, improving facility-based care, and promoting essential newborn care at the household level.

At the beginning of NRHM, preventable conditions such as pneumonia, diarrhoea, neonatal sepsis, birth asphyxia, prematurity, and malnutrition remained major causes of infant and child mortality in India. Many of these deaths occurred because caregivers failed to recognize danger signs or could not access timely medical care. IMNCI addressed these challenges by promoting early diagnosis, standardized case management, and prompt referral of sick children.

Objectives

The major objectives of IMNCI were to:

• Reduce neonatal, infant, and under-five mortality.

• Improve the quality of care for sick newborns and children.

• Strengthen the skills of healthcare providers in the assessment and management of childhood illnesses.

• Promote essential newborn care and appropriate infant feeding practices.

• Encourage early recognition of danger signs and timely referral of seriously ill children.

• Strengthen community participation in newborn and child healthcare.

Programme Strategy

IMNCI adopted an integrated approach rather than treating individual diseases separately. Healthcare providers were trained to assess children holistically, classify illnesses according to severity, provide appropriate treatment, counsel caregivers, and arrange referral whenever necessary.

The strategy was implemented through health facilities as well as community-based services delivered by Auxiliary Nurse Midwives (ANMs), Accredited Social Health Activists (ASHAs), Anganwadi Workers (AWWs), and medical officers.

Management of Pneumonia

Pneumonia remained one of the leading causes of under-five mortality in India. IMNCI emphasized the early identification and treatment of children presenting with cough and difficult breathing.

Health workers were trained to:

• Assess respiratory rate according to age.

• Identify chest indrawing and other danger signs.

• Classify the severity of pneumonia using standardized guidelines.

• Provide appropriate antibiotic treatment for non-severe cases where indicated.

• Refer severe pneumonia cases immediately to higher health facilities.

Caregivers were also educated about the importance of seeking prompt medical attention for children experiencing breathing difficulties.

Management of Diarrhoea

Diarrhoeal diseases continued to be a major cause of childhood morbidity and mortality due to dehydration. Under IMNCI, emphasis was placed on preventing dehydration and ensuring early treatment.

Health workers promoted:

• Oral Rehydration Solution (ORS) therapy.

• Continued breastfeeding during diarrhoea.

• Adequate fluid intake.

• Zinc supplementation, where recommended under national guidelines during the period.

• Recognition of danger signs requiring referral, such as severe dehydration, persistent vomiting, or inability to drink.

Caregiver counselling played an important role in improving home management of diarrhoea and reducing preventable deaths.

Management of Neonatal Infections

The neonatal period (the first 28 days of life) carries the highest risk of mortality. Neonatal infections such as sepsis, pneumonia, and umbilical infections were important contributors to neonatal deaths in India.

IMNCI strengthened the ability of health workers to:

• Recognize signs of serious bacterial infection.

• Identify poor feeding, lethargy, hypothermia, fever, fast breathing, and convulsions.

• Initiate appropriate first-line management where feasible.

• Refer newborns immediately to facilities capable of providing specialized neonatal care.

The programme also promoted clean delivery practices and hygienic cord care to prevent infections.

Home-Based Newborn Care

One of the unique features of IMNCI under NRHM was the emphasis on home-based newborn care, particularly during the first week after birth when neonatal mortality is highest.

ASHAs and ANMs conducted scheduled home visits to:

• Assess the health of the newborn.

• Monitor feeding and breastfeeding practices.

• Counsel mothers on thermal care and hygiene.

• Identify danger signs requiring referral.

• Promote exclusive breastfeeding.

• Educate families regarding newborn care and immunization.

These visits helped ensure continuity of care after discharge from health facilities and improved early detection of complications.

Early Referral

Prompt referral formed an essential component of IMNCI. Health workers were trained to recognize severe illness requiring immediate medical attention and arrange timely referral to higher-level facilities.

Children presenting with any of the following danger signs were referred urgently:

• Inability to feed.

• Persistent vomiting.

• Convulsions.

• Severe respiratory distress.

• Unconsciousness or lethargy.

• Severe dehydration.

• High fever or hypothermia.

The referral strategy was supported by strengthened First Referral Units (FRUs), Community Health Centres (CHCs), and District Hospitals under NRHM.

Capacity Building

Successful implementation of IMNCI required extensive training of health personnel. NRHM supported training programmes for:

• Medical Officers.

• Staff Nurses.

• Auxiliary Nurse Midwives (ANMs).

• Accredited Social Health Activists (ASHAs).

• Anganwadi Workers (AWWs).

Training focused on integrated assessment, disease classification, treatment protocols, counselling techniques, newborn care, and referral practices.

Progress up to 2012

Between 2005 and 2012, IMNCI was gradually expanded across several states under NRHM. Thousands of healthcare providers received IMNCI training, and community-based newborn care practices became increasingly integrated into maternal and child health services.

The programme contributed to improved recognition and management of common childhood illnesses, increased caregiver awareness regarding newborn care, better referral of seriously ill children, and strengthened continuity of care from the household to health facilities. These interventions complemented other NRHM initiatives such as the Universal Immunization Programme, Janani Suraksha Yojana, Facility-Based Newborn Care, and the ASHA programme.

Challenges

Despite its achievements, IMNCI implementation faced several challenges up to 2012. Coverage remained uneven across states and districts, and many health workers had not yet received IMNCI training. High workloads, staff shortages, irregular supportive supervision, and limited availability of essential medicines affected programme implementation in some areas.

Referral systems remained weak in remote districts, while inadequate transport facilities delayed access to specialized neonatal care. Continued efforts were therefore required to strengthen training, supervision, and integration with other child health programmes.

The Integrated Management of Neonatal and Childhood Illness (IMNCI) became an important child survival strategy under the National Rural Health Mission by providing an integrated approach to the prevention, early detection, and management of common neonatal and childhood illnesses. Through improved case management of pneumonia, diarrhoea, and neonatal infections, promotion of home-based newborn care, and timely referral of seriously ill children, IMNCI strengthened both community-based and facility-based child healthcare services. By 2012, the programme had contributed to improved child health service delivery and supported India's efforts to reduce neonatal, infant, and under-five mortality, although further expansion and strengthening remained necessary.

 

4.3 Facility-Based Newborn Care (FBNC)

To reduce neonatal mortality and improve the survival of newborns, the National Rural Health Mission (NRHM) introduced Facility-Based Newborn Care (FBNC) as an essential component of child health services. The programme aimed to provide specialized care for sick, low birth weight, and premature newborns by establishing dedicated newborn care facilities at different levels of the public health system.

Under NRHM, three levels of newborn care facilities were developed:

• Newborn Care Corners (NBCCs): Established in labour rooms and operation theatres to provide immediate essential newborn care, including neonatal resuscitation, thermal protection, and initiation of breastfeeding immediately after birth.

• Newborn Stabilization Units (NBSUs): Established at Community Health Centres (CHCs) and First Referral Units (FRUs) to stabilize sick and low birth weight newborns before referral to higher-level facilities.

• Special Newborn Care Units (SNCUs): Established mainly at District Hospitals to provide intensive care for premature, low birth weight, and critically ill newborns requiring specialized treatment and continuous monitoring.

By strengthening these facility-based services, NRHM improved the management of neonatal complications such as birth asphyxia, sepsis, prematurity, and low birth weight. The establishment of FBNC facilities complemented community-based newborn care and contributed to improving neonatal survival in rural India up to 2012.

.4.4 Nutrition

Recognizing that malnutrition is a major contributor to maternal and child morbidity and mortality, the National Rural Health Mission (NRHM) worked in close coordination with the Integrated Child Development Services (ICDS) to improve the nutritional status of mothers and children. The convergence of health and nutrition services aimed to provide a comprehensive approach to child survival and development.

Key interventions included the promotion of exclusive breastfeeding for the first six months of life, regular growth monitoring of children to identify undernutrition at an early stage, Vitamin A supplementation to prevent deficiency-related illnesses, Iron and Folic Acid (IFA) supplementation to reduce anaemia among children and pregnant women, and early identification and management of childhood malnutrition through counselling, referral, and nutritional support. These coordinated efforts contributed to improving child nutrition and reducing nutrition-related health risks under NRHM up to 2012.

 

5. Health System Strengthening

The National Rural Health Mission (NRHM) introduced several reforms to strengthen the rural public health system by improving human resources, health infrastructure, and decentralized financial management. These reforms aimed to enhance the availability, accessibility, and quality of healthcare services.

Human Resources

To address the shortage of healthcare personnel in rural areas, NRHM supported the recruitment of doctors, appointment of contractual specialists, deployment of additional Auxiliary Nurse Midwives (ANMs), and large-scale training of Accredited Social Health Activists (ASHAs). These initiatives improved the availability of skilled health workers and strengthened the delivery of maternal and child health services.

Infrastructure Development

NRHM invested in the construction, renovation, and upgradation of Sub-Centres (SCs), Primary Health Centres (PHCs), Community Health Centres (CHCs), and District Hospitals. Strengthening health infrastructure enhanced the capacity of public health facilities to provide essential preventive, promotive, and curative healthcare services, particularly in rural and underserved areas.

Untied Funds

To encourage decentralized planning and local decision-making, NRHM provided untied funds to Sub-Centres, Village Health and Sanitation Committees (VHSCs), and public health facilities. These flexible funds enabled local health institutions to meet minor operational expenses, undertake small repairs, procure essential supplies, and respond to community health priorities, thereby improving the efficiency and responsiveness of the rural health system.

Overall, these reforms played a crucial role in strengthening the health system and improving the delivery of maternal, child, and primary healthcare services under NRHM up to 2012.

 

6. Progress up to 2012

Progress of Maternal and Child Health Services under NRHM (up to 2012)

Institutional Deliveries

One of the most significant achievements of the National Rural Health Mission (NRHM) was the substantial increase in institutional deliveries, largely driven by the implementation of the Janani Suraksha Yojana (JSY). Financial incentives, improved health infrastructure, and the support of ASHAs encouraged more pregnant women to deliver in health institutions under the supervision of skilled health personnel.

Maternal Mortality

NRHM interventions contributed to a steady decline in maternal mortality. According to the Sample Registration System (SRS), the Maternal Mortality Ratio (MMR) decreased from 254 per 100,000 live births during 2004–06 to 212 per 100,000 live births during 2007–09, reflecting improved access to maternal healthcare services.

Infant Mortality

Significant progress was also observed in reducing infant mortality. As reported by the Sample Registration System (SRS) 2011, the Infant Mortality Rate (IMR) declined from 58 deaths per 1,000 live births in 2005 to 44 deaths per 1,000 live births in 2011, indicating improvements in maternal, newborn, and child health services.

Immunization

Routine immunization coverage improved considerably under NRHM through better vaccine availability, strengthened cold chain systems, expanded outreach services, and community mobilization. However, disparities in immunization coverage persisted across states and districts.

Community Participation

NRHM promoted community ownership of health services through the establishment of Village Health and Sanitation Committees (VHSCs) in many villages. In addition, Accredited Social Health Activists (ASHAs) played a vital role in increasing community awareness about maternal and child health, encouraging the utilization of health services, and facilitating access to institutional care.

 

 

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