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Indian Journal of Community Medicine

Coverage and Quality of Maternal and Child Health Services at Subcentre Level

Author(s): Sunder Lal, Satish Kapoor, Brij Mohan Singh Vashisht, M.S. Punia

Vol. 26, No. 1 (2001-01 - 2001-03)

Department of Social and Preventive Medicine, Pt. B.D. Sharma PGIMS, Rohtak


Research question: What is the level of coverage and quality of cardinal maternal and child health services at the level of subcentre?

Objective: To assess the coverage and quality of maternal and child health services at the subcentre level.

Setting: Rural area.

Study design: Cross-sectional.

Sample size: Ten functional subcentres, 500 mothers having children between 1-2 years of age, randomly selected from ten subcentres.

Study variables: Antenatal care, delivery practices, postnatal care, contraception, immunization and management of diseases in young children.

Results: Ten functional subcentres could achieve impressive coverage level of 95% in respect of antenatal registration, tetanus toxoid to pregnant women, fully immunized children and deliveries by trained personnel and vitamin-A prophylaxis (first dose). Distressingly low level of coverage of iron and folic acid (5.8%), postnatal care (4.4%) and only 28% of antenatals had three check-ups at subcentre. Quality of antenatal care was graded as excellent in one and good or poor in remaining nine subcentres. Immunization and delivery services were graded as excellent in all the ten subcentres but postnatal care, new born care and contraceptive services were graded as poor in all the subcentres. Diarrhoea management was graded as excellent in one subcentre area while nine of the subcentres were put in the category of good or poor. Similarly, ARI management was considered excellent in 5 subcentres, good in 4 subcentres and poor in one subcentre area.

Keywords: Coverage, Quality, Antenatal, Intranatal, Postnatal and Newborn care,


As the National Family Welfare Programme moved from target based activity to client centered, demand driven, quality service programme, the subcentres and primary health centres are to be geared up to fulfill the aspirations of the people. Subcentre is the first level of formal institution in the set up of primary health care. Coverage and quality of maternal and child health services at the level of subcentre will determine the overall performance level of primary health centre, as also the supportive supervision and back up support for referral services and continuing education. Quality of maternal and child health services and client satisfaction is most vital in the final outcome. Several methods are available for assessing the quality of services, ranging from direct observation, supervision, interview of the target clients as also examination of records and facility surveys1.

Material and Methods:

The endeavour of present study was to assess the coverage and quality of key maternal and child health services at the level of subcentre. Ten functional subcentres were purposely selected. Fifty mothers having children between 1-2 years of age group were chosen from each subcentre area by systematic random sample. A functional subcentre meant that subcentre team contingent of multipurpose health worker male and female and traditional birth attendant, was in position for full one year and essential equipment, materials and supplies made available in that unit. The methodology adopted in the present study comprised of facility survey, clients interview and scoring system for responses to assess the coverage and quality of services provided, during the period from 1996-98.

To assess the quality of services, scoring system was developed. Total score assigned to broad components of maternal and child health services was in the order of antenatal care 15, delivery services 10, postnatal and contraceptive services 10, newborn care 8, diarrhoea management 7, ARI management 5 and immunization 5. Total score for all the broad components added upto 60. Each component of maternal and child health services, was broken up into several elements for the purpose of scoring to ensure fair and wide distribution of scores. Elements for component of antenatal care consisted of trimester of registration, number of contacts with subcentre ANM/doctor, weight and blood pressure recorded, abdominal examination done, dietary advice given, number of packets of IFA taken and high risk antenatals referred. A woman who was registered in first trimester was given a score of 3 while a woman who got registered in third trimester earned a score of zero. Weighing, recording of blood pressure and abdominal examination earned a score of one point each (equal weightage). Score earned by each broad component with its various elements was added up for a set of 50 mothers of respective subcentre unit and percentage for each component was derived. Thereafter, the subcentres were graded as excellent if score was 70% or more, as good with score of 50-69% and poor if score was less than 50%. National norms for coverage of services adopted by state were used to assess the coverage of services.

Observations and Discussion:

Each subcentre covered manageable population of 5000 or less but for one subcentre which covered a population of 5615. Population of subcentre in this area was confined to one village only, saving lot of travel time. All the ANMs were non-resident. 

Table I: Performance of study subcentres against the state norms for MCH services (1996-97).

Activity *Norms (%) Performance(%)
ANCs registered 100 95.2
Early ANC registration (<16 weeks) 60 35.4
ANCs completed 3 visits 100 27.7
ANCs received TT 2 doses 100 94.8
ANCs given IFA prophylaxis (100 tabs.) 50 5.8
High risk ANCs detected and referred 15 1.6
Institutional deliveries 33 14.2
Deliveries by trained persons 100 99.6
PNC completed 3 visits 100 4.4
Birth weight recorded by MPHW(F) 100 29.4
Immunization: 100% of newborns 95.0
BCG DPT (3 doses) 100 99.6
Polio (3 doses) 100 97.8
Measles Children fully immunized 100 97.8
Vit. A solution (first dose) 100 97.2
Diarrhoea cases treated with ORS 100% of episodes 95.0 56.6
Pneumonia cases treated with co-trimoxazole 100 of ARI cases 95.0 49.0
Couple protection rate 21.4
Sterilization 14.8
IUD 4.8
Oral Pills 1.0
Nirodhs 0.8

*Source-Decentralized participatory planning in family welfare programme under Target Free Approach.

A near universal coverage level of over 95% in respect of antenatal registration, deliveries by trained person, immunization for pregnant women and infants, vitamin A first dose, was achieved in the area under study. This could be attributed to combined efforts of integrated child development services and health infrastructure as also adequate facilities made available in functional subcentres. However, the coverage of services for iron and folic acid full course (5.8%), postnatal care three visits (4.4%) and weighing of births (29.4%) achieved poor level of coverage, despite adequate availability of iron and folic acid tablets and weighing scale with multipurpose health worker female at the subcentre. The study does not reveal the true couple protection rate as selective eligible couples were included in this study (women having children between 1-2 years of age included in the study), hence couple protection rate of 21.4%, however, the use of spacing methods by this target group was low (around 6%) and use of condom was quite low at 0.8%. High coverage level as observed for key maternal and child health services did not correspond with level of quality coverage; as only 28% antenatals received three check-ups and 35% of them were registered early (in the first trimester of pregnancy).

Table II: Score obtained by subcentres for MCH services (Percentages).
Name of subcentres Antenatal care Intranatal care Postnatal care Contraception Newborn care Immunization Diarrhoea ARI
Chiri (A) 51.0 85.6 17.3 9.3 54.6 86.8 44.7 75.0
Chiri (B) 50.8 89.6 9.3 21.0 47.0 88.4 44.0 53.0
Chandi 73.7 89.6 32.3 23.5 44.3 91.6 27.4 28.0
Gironthi 63.6 89.2 14.3 16.6 44.0 84.4 41.0 66.0
SG Pur 50.8 88.0 12.3 27.7 41.0 86.0 55.2 84.0
Sunderpur 44.8 89.6 11.0 16.6 39.0 87.2 48.7 53.0
Bhagwatipur 47.4 90.0 11.0 21.4 46.0 91.6 84.2 71.4
Bainsi 51.5 88.8 13.0 11.0 42.3 93.2 49.2 60.0
Bahuakbarpur (A) 42.2 90.5 15.0 15.0 46.0 87.0 53.7 73.0
Bahuakbarpur (B) 55.7 90.0 20.3 29.0 41.3 82.4 54.6 89.3

Table III: Grading of subcentres on the basis of score obtained for quality MCH services.

Grading of subcentre Spectrum of MCH services
Antenatal care Intranatal care Postnatal care Contraception Newborn care Immunization Diarrhoea management ARI management
Excellent 1 10 - - - 10 1 5
Good 6 - - - 1 - 3 4
Poor 3 - 10 10 9 - 6 1

One out of ten subcentres was graded as excellent for component of antenatal care and the remaining were placed in the categories of good or poor. Referral of high risk antenatal was poor (1.6%). Though all the subcentres achieved excellent grading for intranatal care, however, 47.6% of deliveries were clean deliveries wherein all the cleans were observed, thus quality of deliveries leaves much to be desired as revealed through scoring of elements of clean deliveries. Coverage and quality of postnatal care was quite dismal as all the ten subcentres were graded as poor for this component and same held true for new born care. Component of universal immunization was much stronger as all the ten subcentres were graded as excellent for coverage and quality. Quality of diarrhoeal diseases management at the subcentre was excellent in one subcentre area, good in three and poor in remaining six subcentres. Similarly, quality of management of ARI was excellent in five subcentres, good in four and poor in one subcentre area (Table II and III).

A study concluded by ICMR task force in 1993 which covered 59 PHCs, 655 subcentres of 14 states indicated significant improvement in the quality and coverage of maternal and child health and family planning services (MCH and FP) at PHC and subcentre level within two years of intervention period2. The intervention comprised of reorientation training of health functionaries for improving their managerial, technical and supervisory skills for comprehensive MCH and FP services, community education and improving the data recording and feedback system at PHC and subcentre level. The results under programme conditions could be much different3. After training and retraining of health functionaries by district training teams and continuing education and supervision by medical officers and supervisors has not produced the desirable improvement in coverage and quality in the area of early registration of antenatals, three check-ups of antenatals and full compliance of iron and folic acid tablets, referrals of high risk antenatals, postnatal care, neonatal care and weighing of births. Similarly, management of diarrhoeal diseases and ARI at the level of subcentre needs much improvement.

The nation has established the capacity to universalize primary health care and maternal and child health care services are being delivered as an integral part of primary health care system. Health centres and subcentres are in existence since independence with well defined functions. Over the years, several evolutions have taken place to improve the functions of subcentres and PHCs. As of now the subcentres are centrally funded and primary health centres are primarily state funded and because of this strategy much more inputs have flown into the network of subcentres for essential maternal and child health services. There is now a positive shift in the programme since 1996. The spectrum of services has been enlarged and emphasis has shifted from number of cases to quality and coverage of services as also client satisfaction. Full range of maternal and child health services has been the concern with decentralized planning driven by client needs. Microplan for family planning and maternal and child health services has been initiated at the subcentre level with active involvement of the community.

Conclusion and Recommendations:

The present study concludes that through close collaboration of ICDS system, high level of registration of antenatal mothers has been ensured, now it is left to health workers to ensure early contact and enough contacts for full range of antenatal services. Holding outreach sessions on maternal and child health once a week on fixed day on the pattern of outreach immunization session is essential to improve quality and coverage of services. Adequate support system of primary health centre must be ensured on sustainable basis through fixed tour programme and supervisory visits. To make microplan and work schedule of subcentres more effective the health workers should spend more time with 30% of economically weaker section mothers whose needs over weigh the rest of mothers, because of higher risk of poor health. Because of non-resident status of health workers, only 5% of deliveries could be conducted by them. It thus becomes imperative to support trained traditional birth attendants (TBAs) by establishing functional linkages with subcentre as also revival of incentive to TBA at revised rate of Rs. 25 per delivery as also provision of disposable dai kits to TBA. Mothers meeting and meeting of mahila swasthya sangh and mahila mandal at the village level should become regular feature with focus on maternal and child health services. Under the present circumstances the postnatal care and early neonatal care are very weak in terms of coverage as also in quality. The Services for majority of children begin around two months of age when the activity of universal immunization gets initiated and similarly, services for women begin whenever pregnancy is detected.

In all the ten subcentres, the health workers female were not resident and lived outside the service area. This is a long standing problem, solutions are not easy. Reforms in this direction are essential to have a policy of recruiting local resident health workers. Panchayat Raj Act of 1992 may have profound effect if subcentres are placed under panchayat control.

The monitoring reports of subcentre (monthly activity report) does provide an account of quality of maternal and child health services, however, these reports are quite cumbersome, incomplete, untimely and quality of records being poor, hopefully these are reviewed and become an instrument for improvement of quality of MCH services. Rapid household survey under reproductive and child health (RCH) programme is another landmark in providing coverage indicators and limited quality indicators at the district level. Similarly, the National Family Health Survey (NFHS) data providing information at state level may serve as stimulus to state and district level authorities to improve the coverage and quality of services, but local data is utmost important, which is seldom collected and much less used for assessment and improvement of services4,5.

The results of present study have ben disseminated to local district and state of Haryana for effecting appropriate improvement and in quality of services. The results of present study are also useful to validate the results of rapid household survey of the district in which this study has been undertaken.


  1. Govt. of India. Manual on decentralized participatory planning in family welfare programme. New Delhi: Ministry of Health and Family Welfare; 1996.
  2. Indian Council of Medical Research. Improving the quality and coverage of maternal and child health and family planning services at primary health centre level. An ICMR Task Force Study (summary report). New Delhi: ICMR; 1993.
  3. Roy TK, Pandey A, Ram F, Murthy MN, Mathurarayagan S. IIPS Mumbai status paper for regional consultation meeting for east zone on research priorities in RCH and nutrition, held on 28-29 Oct. 1999 at Calcutta, Organized jointly by ICMR and UNICEF, New Delhi.
  4. Kumar V. Study of mortality in rural community development block Lakhanmajra, Rohtak. [Thesis]. Rohtak MD University; 1998.
  5. Kapoor S. Evaluation of selected maternal and child health services at subcentre level in rural community development block Lakhanmajra, Rohtak. [Thesis]. Rohtak MD University; 2000.
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