What is the approach to Reproductive, Maternal, Newborn, Child Health, and Nutrition (RMNCAH+N)?

RMNCAH+N Approach: Integrated Continuum of Care

The RMNCAH+N approach is a comprehensive, integrated health system framework that delivers reproductive, maternal, newborn, child, adolescent health, and nutrition services across the entire life course through a hierarchical delivery network linking community-based primary care to specialized referral facilities, with emphasis on equity-focused targeting and quality-adjusted coverage measurement. 1

Core Framework Structure

The approach operates as a continuum of care rather than isolated interventions, integrating services across multiple life stages 1:

Reproductive Health Services

• Family planning services including contraceptive education and access with reproductive life planning 1
• Prepregnancy visits for risk assessment, health promotion, and targeted interventions for couples planning conception 1
• Interconception care focusing on reducing medical, dental, and psychosocial risks between pregnancies, particularly for women with previous adverse outcomes 1

Maternal and Newborn Care

• Risk-stratified maternal care delivery through four levels: birth centers, basic care (Level I), specialty care (Level II), subspecialty care (Level III), and regional perinatal health centers (Level IV) 2
• Regionalized systems where high-risk pregnant women receive care in facilities prepared to provide required specialized care, thereby reducing maternal morbidity and mortality 2
• Postpartum visits for maternal health monitoring and interconception care planning 1

Child and Adolescent Components

• Immunization programs through expanded immunization schedules 1
• Mental health services for children and adolescents 1

Implementation Architecture

Service Delivery Network

• Hierarchical maternal and child health delivery network with strong community roots, linking primary health centers to referral facilities 1
• Integrated service provision across the continuum to avoid fragmented delivery 1
• Primary care-based systems rather than hospital-centric models 1

Quality and Coverage Measurement

The approach requires six-step coverage framework moving beyond simple contact metrics 3:

1. Target population identification
2. Service contact
3. Crude coverage measurement
4. Quality-adjusted coverage (critical gap: 10-38 percentage point drops from crude to quality-adjusted measures) 3
5. User-adherence-adjusted coverage
6. Outcome-adjusted coverage 3

• Coverage monitoring through household surveys to track intervention reach and identify underserved populations 1
• Data disaggregation by wealth, geography, and ethnicity to identify and address inequalities 1
• Facility-based service quality assessments supplementing household surveys 1

Equity-Focused Implementation

Targeting Vulnerable Populations

• Equity-focused targeting to address gaps among the poorest, least educated, and rural populations 1
• Geographic prioritization for northern and eastern regions showing significant socioeconomic disparities 4
• Urban and rural poor focus, particularly in underserved areas 4

Financial Protection Mechanisms

• Expanded health insurance coverage for low-income women to ensure access to preventive and curative services 1
• Free essential services for communicable diseases and RMNCAH interventions through government financing 1

Critical Implementation Pitfalls to Avoid

Service Integration Failures

• Avoid fragmented service delivery by ensuring true integration rather than parallel programs 1
• Prevent hospital-centric bias by prioritizing primary care-based integrated systems 1
• Address facility-based intervention gaps which demonstrate poor coverage and high inequalities (skilled birth attendance shows 61.6% absolute difference between wealthiest and poorest quintiles) 4

Quality Gaps

• Recognize that service contact does not equal effective coverage - substantial drops occur between crude coverage and quality-adjusted measures 3
• Address provider-level factors including gender norms and unsupportive working conditions that lead to poor treatment of clients 5
• Ensure regulatory alignment - midwives and other providers must have legal authority to deliver expected services (baseline gaps can be as high as 80% of expected interventions) 6

System Weaknesses

• Critical shortage of human resources across all levels requires innovative capacity-building approaches 7
• Lack of medicines and supplies must be systematically addressed 7
• Low national funding requires advocacy for increased health budget allocation 7

Lifespan Approach Principles

Preconception care must be tailored across the lifespan, not delivered as a single visit 2:

• Different interventions for different life stages - a nulliparous young woman requires different health promotion than a 35-year-old woman with three children 2
• Intensive interventions for women with chronic diseases, previous pregnancy complications, or behavioral risk factors 2
• Ongoing monitoring rather than episodic care, similar to well-child care and adult wellness models 2

Person-Centered Care Requirements

• Respect, privacy, confidentiality, and non-discrimination as integral principles 5
• Informed decision-making based on individuals' preferences, needs, and values 5
• Provider support to address factors leading to poor treatment of clients 5