Endometrial Hyperplasia

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Endometrial Hyperplasia — Diagnosis & Management

Endometrial hyperplasia is a precursor of endometrial cancer, driven by unopposed oestrogen. This sheet gives the classification and cancer risk, how to investigate abnormal bleeding, treatment with and without atypia, fertility-sparing care, and follow-up.

🎯 AT A GLANCE — ENDOMETRIAL HYPERPLASIA

Endometrial hyperplasia is an overgrowth of the endometrial glands, most often from oestrogen that is not balanced by progesterone

The WHO 2014 system has two groups: hyperplasia without atypia (benign) and atypical hyperplasia, also called EIN (premalignant)

Without atypia, progression to cancer is under 5% over 20 years; with atypia the risk is much higher, and cancer is already present in up to 43% of hysterectomy specimens

It usually shows as abnormal uterine bleeding, and it is diagnosed only by histology

Treatment: the LNG-IUS for hyperplasia without atypia, and hysterectomy for atypical hyperplasia when fertility is complete

Any woman with postmenopausal bleeding, or persistent abnormal bleeding with risk factors, needs an endometrial assessment.

🚨 ESCALATE OR DO NOT ASSUME BENIGN IF…

The biopsy shows atypical hyperplasia — refer to a gynaecologist; cancer may already be present, so do not treat in the primary care clinic

Bleeding after menopause — assess with transvaginal ultrasound and sampling; a thickness of 3–4 mm or less makes cancer very unlikely

Bleeding continues despite a negative biopsy — about 2% of negative biopsies miss hyperplasia; do hysteroscopy

A polyp contains hyperplasia, or a focal lesion is seen — remove it fully with hysteroscopy and sample the surrounding endometrium

There is no regression after 12 months of treatment, or the hyperplasia relapses or progresses to atypia — offer hysterectomy if she has completed her family

STEP 1 · UNDERSTAND IT — what it is and who is at risk

🔬 CLASSIFICATION AND RISK

Older WHO 1994 term	WHO 2014 group	Meaning
Simple or complex hyperplasia (no atypia)	Hyperplasia without atypia	Benign; gland pattern no longer part of the grading; usually regresses with treatment or with the cause removed
Simple or complex hyperplasia with atypia	Atypical hyperplasia (EIN)	Premalignant; the guideline treats EIN and atypical hyperplasia as interchangeable

📋 RISK FACTORS AND CAUSES

Obesity: fat cells convert androgens to oestrogen

Anovulation: perimenopause and polycystic ovary syndrome leave oestrogen unopposed by progesterone

Oestrogen-secreting ovarian tumours, such as granulosa cell tumours

Oestrogen-only HRT in a woman with a uterus, and long-term tamoxifen

Also: nulliparity, diabetes and a family history of endometrial or colorectal cancer (from memory)

Ask every woman with abnormal bleeding: weight, cycle pattern, HRT, tamoxifen, and family history of cancer.

STEP 2 · DIAGNOSE — history, scan and sampling

🩺 INVESTIGATION

Histology is required for the diagnosis; the scan only suggests it

Outpatient endometrial biopsy is the first test; it detects hyperplasia well (positive likelihood ratio 12), but about 2% of negative biopsies still hide it

Hysteroscopy when sampling fails or is inadequate, when hyperplasia is in a polyp or focal lesion, or when bleeding persists

Transvaginal ultrasound, postmenopausal bleeding: 3–4 mm or less rules out cancer in over 99% of cases; use a higher cut-off on HRT or tamoxifen

Premenopausal women with PCOS: no hyperplasia was found when the endometrium was under 7 mm

Do not use CT, MRI or blood biomarkers routinely

Women under 45 with persistent abnormal bleeding, or any age with risk factors, deserve sampling (from memory)

STEP 3 · MANAGE — by histology and by what she wants

🌿 HYPERPLASIA WITHOUT ATYPIA

Counsel her, correct reversible causes (weight loss if BMI is over 30; stop or change oestrogen-only HRT), and offer observation with repeat biopsies when she has no heavy bleeding

Regression with progestogens is about 89–96%, and with observation alone about 74–81%

First choice: the levonorgestrel IUS (better regression, better bleeding control and fewer side effects than tablets)

If she declines the IUS: continuous oral progestogen: medroxyprogesterone 10–20 mg a day or norethisterone 10–15 mg a day. Cyclical progestogens are not recommended

Treat for at least 6 months; the LNG-IUS can stay up to 5 years if tolerated and fertility is not wanted

Biopsy every 6 months; discharge after two consecutive negative biopsies. Women with a BMI of 35 or more, or on oral progestogen, need annual follow-up afterwards

Hysterectomy is not first line; offer it for progression to atypia, no regression at 12 months, relapse, persistent bleeding, or when she declines surveillance

Endometrial ablation is not recommended

⚠️ ATYPICAL HYPERPLASIA (EIN)

Standard treatment: total hysterectomy, laparoscopic if possible; do not use supracervical hysterectomy

Postmenopausal: remove both tubes and ovaries. Premenopausal: decide about the ovaries together with her; consider removing the tubes

Avoid morcellation; frozen section is not reliable; routine lymph node removal is not needed

Imaging and CA-125 beforehand when needed, to exclude cancer

Ablation or resection is not recommended

Cancer may already be there: send the uterus for full histology and review the result with a gynaecological oncology team.

🤰 FERTILITY-SPARING CARE FOR ATYPICAL HYPERPLASIA

Counsel about the cancer risk and get a multidisciplinary review; first exclude invasive or ovarian cancer with CA-125 and ultrasound or MRI

First line: the LNG-IUS; oral progestogens are second best

Regression is about 86%, relapse about 26%, and live birth about 26% in observational data

Biopsy every 3 months until two negative results, then every 6–12 months

If there is no regression by 12 months, or cancer is found, hysterectomy is strongly recommended

Confirm regression before she tries to conceive; offer hysterectomy once the family is complete

💊 HRT, TAMOXIFEN AND OTHER SITUATIONS

HRT: never give oestrogen alone to a woman with a uterus; on sequential HRT switch to a continuous progestogen or the LNG-IUS, and stopping may be enough to induce regression

Tamoxifen: raises the risk of hyperplasia and cancer; review with the oncologist if hyperplasia develops

Polyps: remove completely and sample the endometrium around it; background hyperplasia is found in about half

Obesity: advise weight loss, because a BMI of 35 or more raises the chance of relapse on the LNG-IUS; for conception aim for a BMI under 30

Bleeding after treatment: tell her to come back at once; relapse needs a new biopsy

⚠️ COMMON PITFALLS

Treating abnormal bleeding with tablets without a biopsy in a woman at risk

Treating atypical hyperplasia with progestogens alone when she has finished her family

Giving cyclical progestogen, which is not recommended

Stopping surveillance after one negative biopsy

Using endometrial ablation, which hides the problem and blocks later sampling

Missing HRT or tamoxifen as the cause

Forgetting to deal with weight, which drives recurrence

Memory Aid

GLAND

Five reminders for endometrial hyperplasia.

G

Get a biopsy — histology makes the diagnosis

L

LNG-IUS first — for hyperplasia without atypia

A

Atypia means hysterectomy — when the family is complete

N

No oestrogen alone — and no cyclical progestogen

D

Do follow-up — repeat biopsy at 6 months, weight loss, and report bleeding

Remember: most hyperplasia without atypia can be reversed; atypia needs a gynaecologist because cancer may already be present.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: RCOG/BSGE Green-top Guideline No. 67 on the management of endometrial hyperplasia (classification, cancer risk, investigation, progestogen doses, surveillance, hysterectomy, fertility-sparing care, HRT, tamoxifen, polyps, obesity) and a review of the WHO 2014 classification (EIN criteria, coexisting carcinoma). Items marked “from memory” (extra risk factors, the age threshold for sampling) were not checked. Guidelines are updated and differ between countries: follow your local protocol and involve a gynaecologist, and a gynaecological oncology team when cancer is possible.

Bacterial Vaginosis

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Bacterial Vaginosis — Diagnosis & Treatment

Bacterial vaginosis is the commonest cause of abnormal discharge in reproductive-age women. This sheet gives how to recognise it, how to confirm it at the bedside, the treatment options, and what to do in pregnancy and when it keeps coming back.

🎯 AT A GLANCE — BACTERIAL VAGINOSIS (BV)

BV is the commonest cause of abnormal vaginal discharge in women of reproductive age

It is an imbalance, not a classic infection: protective lactobacilli are replaced by anaerobic bacteria, and the vaginal pH rises

Typical picture: thin white or grey, non-itchy discharge with a fishy smell, worse after sex

It is treated with metronidazole or clindamycin; it often comes back, so look for the contributing factors

BV is not classed as a sexually transmitted infection, but sexual activity is a risk factor (from memory)

Not every discharge is BV: check for trichomonas, candida and cervicitis, and take a sexual history.

🚨 DO NOT JUST TREAT AS BV IF…

She has lower abdominal pain, fever, pain with sex or bleeding between periods — think of pelvic inflammatory disease; examine and test for STIs (from memory)

The discharge is yellow-green, frothy or itchy, or the cervix looks inflamed — test for trichomonas, gonorrhoea and chlamydia (from memory)

She is pregnant and has had a previous preterm birth or late miscarriage, or has symptoms — treat and involve the obstetrician (from memory)

Bleeding after sex, a visible cervical lesion, or blood-stained discharge — examine the cervix and do a Pap or HPV test as due; it is not BV (from memory)

Symptoms return again and again — re-check the diagnosis, adherence and contributing factors before repeating the same course

STEP 1 · RECOGNISE IT — what is going on and how it presents

🔬 WHAT HAPPENS IN BV

The normal vagina is dominated by lactobacilli, which make lactic acid and keep the pH below 4.5

In BV the lactobacilli fall and anaerobes such as Gardnerella and others increase, and the pH rises to 4.5–6.0

Contributing factors: unprotected sex or a new partner, vaginal douching, smoking, and copper IUCD use (the last from memory)

Many women have no symptoms; those who do notice a thin, white or grey, malodorous discharge, often fishy and worse after sex

It is usually not itchy or painful; itch, soreness or pain suggest another cause

🩺 SIGNS AND SYMPTOMS: BV OR SOMETHING ELSE?

Feature	Bacterial vaginosis	Candida	Trichomonas
Discharge	Thin, white or grey, sticks to the walls	Thick, white, curd-like	Frothy, yellow-green
Smell	Fishy	None or mild	Offensive
Itch or soreness	Little or none	Marked	Common
pH	Above 4.5	Normal (4.5 or below)	Above 4.5
Cervix and vulva	Not inflamed	Red, may have fissures	May look inflamed (strawberry cervix)

Typical patterns, mostly from memory; they overlap, so test when the picture is unclear.

STEP 2 · DIAGNOSE — simple bedside tests

🧪 CONFIRMING THE DIAGNOSIS

Test	What it shows
Amsel criteria (diagnose BV when 3 of 4 are present)	1. Thin, white-grey homogeneous discharge · 2. Vaginal pH above 4.5 · 3. Positive whiff (amine) test: fishy smell when 10% KOH is added · 4. Clue cells on wet-mount microscopy (from memory)
Gram stain (Nugent score)	Counts the bacterial types; a high score means BV. Used in laboratories and research (from memory)
High vaginal swab	Gram stain alone should not be used to diagnose BV; treatment can start without a swab
STI screen	Offer when there is risk or other symptoms; take a sexual history

STEP 3 · TREAT — who, what and how long

💊 TREATMENT OPTIONS

Option	Regimen	Points to remember
Oral metronidazole (first choice)	400 mg twice daily for 5–7 days (7 days in some guidelines)	As effective as topical treatment and cheaper. Avoid alcohol during treatment and for at least 48 hours after
Single-dose oral metronidazole	2 g once	More relapse at 4 weeks than the 7-day course; avoid in pregnancy and breastfeeding
Metronidazole vaginal gel 0.75%	5 g applicator at night for 5 nights	An alternative when oral drugs are not tolerated
Clindamycin 2% vaginal cream	5 g applicator at night for 7 nights	Can weaken latex condoms and diaphragms: do not rely on them during treatment and for 72 hours after. Avoid in colitis or inflammatory bowel disease and in the first trimester
Oral clindamycin (second choice)	300 mg twice daily for 7 days	Risk of Clostridioides difficile infection

Regimens are from published guidance and differ slightly between countries. Check allergy and, with metronidazole, advise a metallic taste, nausea and the alcohol warning.

🤰 PREGNANCY, PARTNERS AND RECURRENCE

Pregnancy: metronidazole is the treatment of choice; avoid the 2 g single dose and avoid clindamycin cream in the first trimester

Pregnancy risks: BV is linked with preterm birth and late miscarriage, so involve the obstetrician when there is a history (from memory)

Male partners: routine treatment is not needed; evidence is limited, though it may be considered in recurrent BV

Female partners: BV is common between women; consider assessing and treating symptomatic partners (from memory)

Recurrent BV: re-check the diagnosis, adherence and contributing factors (unprotected sex, douching, smoking); consider lactic acid vaginal gel

For frequent recurrences, longer suppressive metronidazole treatment is used in specialist care (from memory)

📋 COUNSEL EVERY WOMAN

Do not douche or use perfumed washes and soaps in the vagina

Wash the vulva gently with water or plain soap (from memory)

Take the full course, even when the smell has gone

No alcohol for the course and for at least 48 hours after metronidazole

Use condoms, and ask her to stop smoking if she smokes

Return if the symptoms come back, or if she develops pain, fever or bleeding

⚠️ COMMON PITFALLS

Treating every discharge as BV or thrush without examining

Missing trichomonas, chlamydia or gonorrhoea in a woman at risk

Giving the 2 g single dose to a pregnant woman

Forgetting the alcohol warning with metronidazole

Relying on a condom during clindamycin cream treatment

Repeating the same course again and again without looking for a cause

Treating a swab report of “Gardnerella” in a woman with no symptoms (from memory)

Memory Aid

FISHY

Five reminders for bacterial vaginosis.

F

Fishy smell — thin discharge, usually not itchy

I

Increased pH — above 4.5

S

Screen for STIs — when there is risk or other symptoms

H

Handle with metronidazole — 5–7 days, no alcohol

Y

Why again? — look for douching, new partners and smoking

Remember: BV is common and treatable, but it often returns; good counselling prevents repeat visits.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the HSE (Ireland) bacterial vaginosis guideline (definition, pH, treatment regimens, pregnancy, partners, recurrent BV, counselling) and an NHS Forth Valley antimicrobial guidance page (oral, single-dose and vaginal metronidazole, clindamycin cream, pregnancy, relapse, partners). Items marked “from memory” (Amsel criteria and Nugent score, comparison of discharge types, STI and pregnancy risks, suppressive therapy for recurrence) were not checked. Regimens differ between countries: follow your local protocol.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Endometriosis — Diagnosis, Pain & Fertility

Endometriosis is a common, long-term cause of pelvic pain and infertility that is often diagnosed late. This sheet gives how to suspect it, how to diagnose it without waiting for surgery, the pain treatment ladder, surgery, and care when she wants to conceive.

🎯 AT A GLANCE — ENDOMETRIOSIS

Endometriosis is tissue like the lining of the womb growing outside the uterus, most often on the ovaries and pelvic peritoneum; it causes inflammation, pain and infertility

About 10% of women of reproductive age are affected, roughly 190 million worldwide (WHO)

It takes on average 4 to 12 years to be diagnosed; painful periods are too often dismissed as normal

There is no cure; treatment controls symptoms and protects fertility, and it can start without surgery

25–50% of women with infertility have endometriosis (WHO)

Think of it in any girl or woman with severe period pain, pain with sex, painful bowel or bladder symptoms, or trouble conceiving.

🚨 REFER URGENTLY OR ESCALATE IF…

Sudden severe pelvic pain with fever, fainting or a tender mass — think of a ruptured or twisted endometrioma, or another acute surgical cause (from memory)

A pelvic mass with solid parts, rapid growth, ascites, or suspicious scan features — manage as a possible ovarian cancer; refer to a gynaecological oncology service (from memory)

Cyclical blood in urine or stool, or pain with passing urine or stool — possible bladder or bowel disease; refer to a specialist centre (from memory)

Back or flank pain, or a dilated kidney on scan — deep disease can block a ureter and silently damage the kidney; image the urinary tract and refer (from memory)

Pain or bleeding after menopause in a woman with known endometriosis — needs evaluation; disease can stay active and transform rarely

STEP 1 · UNDERSTAND IT — what it is and how it presents

🔬 WHAT IT IS AND WHO GETS IT

Lesions respond to hormones, bleed and cause inflammation and scarring; deep endometriosis means lesions more than 5 mm below the peritoneal surface

Main forms: superficial peritoneal disease, ovarian endometrioma (the “chocolate cyst”), and deep endometriosis involving bowel, bladder, ureter or uterosacral ligaments

Most likely mechanisms: retrograde menstruation (Sampson’s theory) together with immune, hormonal and genetic factors; the cause is not fully known (from memory)

Risk factors: family history, early menarche, short cycles, and conditions that obstruct menstrual outflow

It can occur outside the pelvis, in the abdomen or chest, and may be present after menopause

🩺 SYMPTOMS TO ASK ABOUT

Pain

Severe period pain (dysmenorrhoea)

Deep pain during sex (dyspareunia)

Chronic pelvic pain; shoulder-tip pain

Bowel and bladder

Painful bowel movements (dyschezia)

Cyclical bloating, nausea or diarrhoea

Painful urination at periods

Bleeding and fertility

Heavy periods or spotting

Difficulty getting pregnant

Tiredness and low mood

Life impact

School or work absence

Effects on relationships and sex

Anxiety and depression

Symptom severity does not match the stage of disease: a woman with small lesions can have severe pain.

STEP 2 · DIAGNOSE — history, imaging, and when to operate

🧭 THE DIAGNOSTIC PATHWAY

Examination can find deep nodules or an endometrioma, but its accuracy is low; a normal examination does not rule it out

Use ultrasound or MRI; a negative scan does not exclude superficial disease

Do not use blood, menstrual or tissue biomarkers (including CA-125) to diagnose it

Laparoscopy is no longer the gold standard; use it when imaging is negative and empirical treatment failed or is not suitable. Histology confirms lesions but a negative result does not exclude disease

Consider the Endometriosis Fertility Index (EFI) when planning fertility after surgery

🧒 ADOLESCENTS AND OLDER WOMEN

Adolescents: suspect it with chronic or cyclical pelvic pain, school absence, family history, early menarche or an obstructed outflow tract

Use transvaginal ultrasound where appropriate; CA-125 is not recommended

First line: hormonal contraceptive or progestogen, including the LNG-IUS; NSAIDs when hormones are not an option

Tell adolescents how the disease can affect ovarian reserve

After menopause: disease can remain active; surgery may confirm the diagnosis, and aromatase inhibitors may help if surgery is not possible

STEP 3 · TREAT THE PAIN — ladder of treatment

💊 MEDICAL TREATMENT OF PAIN

Step	Options	Points to remember
1 · Analgesia	NSAIDs or other analgesics, alone or together	Offer from the start; take with food; check kidney and stomach risks (from memory)
2 · Hormones, first line	Combined pill (may be taken continuously for period pain), progestogens (for example dienogest), LNG-IUS, etonogestrel implant	Hormonal treatment is an option for all; use shared decision-making. Irregular bleeding is common with progestogens
3 · Second line	GnRH agonists with combined add-back therapy; GnRH antagonists may be considered	Add-back therapy prevents bone loss; antagonists are a second-line option for pain
4 · Refractory pain	Aromatase inhibitors, alone or with other hormones	For pain that has not responded to other medical or surgical treatment; may not suit women who want to conceive
Supportive care	Physiotherapy, cognitive behavioural therapy, pain services	Include psychological support, especially with deep or ovarian disease

Do not give hormones before surgery to improve operative outcomes. After surgery, hormonal treatment may be offered if pregnancy is not desired right away. Product choice and doses depend on local availability: follow your protocol.

🔪 SURGERY

Surgery is one option for pain, by laparoscopy; excision may be considered over ablation

Endometrioma: cystectomy rather than drainage and coagulation, taking care to protect the ovary

Deep endometriosis: surgery may reduce pain and improve quality of life; refer to a centre of expertise

Hysterectomy: only for women who no longer want children and did not respond to conservative treatment; it may not cure the symptoms

Recurrence is common without postoperative hormonal treatment, so discuss it before the operation

Counsel before surgery: effect on ovarian reserve, risk of bowel, bladder and ureter injury, and chance of recurrence.

STEP 4 · INFERTILITY — protecting the chance of pregnancy

👶 WHEN SHE WANTS TO CONCEIVE

Hormonal suppression does not improve fertility; do not use it for that purpose, and do not use it after surgery just to raise pregnancy rates

Mild disease (stage I/II): laparoscopic surgery may be offered; IUI with ovarian stimulation may be used

Endometrioma or deep disease: surgery may help natural conception in symptomatic women, but weigh the risk to ovarian reserve

Assisted reproduction (IVF/ICSI) is indicated for tubal damage, male factor, a low EFI, or failure of other treatment; it does not raise the recurrence rate

Do not routinely operate before IVF for stage I/II disease or endometrioma; operate for pain or if follicles cannot be reached

Discuss fertility preservation when ovarian disease is extensive; its benefit is not yet certain

⚠️ COMMON PITFALLS

Telling a girl that painful periods are normal

Waiting for laparoscopy before starting treatment

Relying on CA-125 or a normal scan to rule it out

Using GnRH analogues without add-back therapy

Treating the scan and ignoring the woman’s pain and distress

Operating on an endometrioma before IVF without a clear reason

Using oestrogen-only hormone therapy after menopause in a woman with endometriosis

Memory Aid

PAIN

Four reminders for the woman with suspected endometriosis.

P

Period pain that stops life — believe her and ask about school and work

A

Ask about sex, bowel and bladder pain — these point to deeper disease

I

Image, do not wait for surgery — ultrasound or MRI, then treat

N

Next step by plan — pain ladder or fertility plan, and refer when deep disease or a suspicious mass is found

Remember: endometriosis is a long-term condition; shared decisions, steady follow-up and psychological support matter as much as the drug or the operation.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Checked against: the WHO endometriosis fact sheet (October 2025: prevalence, symptoms, delay to diagnosis, treatment options) and the ESHRE 2022 endometriosis guideline (diagnosis, imaging, laparoscopy, hormonal and surgical treatment, infertility, adolescents, menopause). Items marked “from memory” (mechanism, ovarian cancer warning signs, acute and urinary tract warnings, analgesic cautions) were not checked, and specific drug doses are intentionally not given. Guidelines differ between countries and products differ in availability: follow your local protocol and involve a senior gynaecologist.

SWARAJ HOSPITAL & RESEARCH INSTITUTE

BOLANGIR, ODISHA  •  OBSTETRICS & GYNAECOLOGY CLINICAL PATHWAY SERIES

Clinician Reference Infographic

Government Programs for Reproductive and Child Health

Government programmes give women and children free, continuous care and financial support. This guide covers the framework, pregnancy and childbirth schemes, newborn and child programmes, immunisation, adolescent and family planning services, social protection, and how to use them, following the JANANI approach.

🎯 AT A GLANCE — GOVERNMENT PROGRAMMES

India's programmes follow a continuum of care: adolescence, family planning, pregnancy, childbirth, the newborn, infancy, and childhood — delivered mainly through the National Health Mission (NHM) and its Reproductive, Maternal, Newborn, Child and Adolescent Health (RMNCH+A) strategy

Free care is an entitlement: delivery (including caesarean section), drugs, diagnostics, blood, diet, and transport in government facilities — women and sick infants should never be turned away

Frontline link: the ASHA (Accredited Social Health Activist), the auxiliary nurse midwife, and the Anganwadi worker register, counsel, escort, and follow up

Core tools: the Mother and Child Protection (MCP) card, the U-WIN digital immunisation platform, 108 and 102 ambulances, and Maternal Death Surveillance and Response

Odisha is classed as a Low Performing State for Janani Suraksha Yojana, so women in Odisha receive the higher package

Know the entitlements and refer into the right scheme — a woman who cannot pay should still receive full care

🚨 ENTITLEMENTS NEVER TO DENY

Free normal and caesarean delivery, drugs, consumables, diagnostics, blood, and diet in government facilities (Janani Shishu Suraksha Karyakram)

Free transport from home to facility, between facilities, and back home — for pregnant women and sick infants

Free treatment for sick newborns and infants up to 1 year (Janani Shishu Suraksha Karyakram, extended in 2013)

Free routine vaccines for children and pregnant women under the Universal Immunisation Programme

Respectful care with no informal payments (Surakshit Matritva Aashwasan, 'zero denial')

🗺️ THE CONTINUUM OF CARE AND THE PROGRAMME AT EACH STAGE

1 · AdolescenceRashtriya Kishor Swasthya Karyakram, Anaemia Mukt Bharat, HPV vaccine

2 · Family planningContraceptive basket, sterilisation, safe abortion

3 · PregnancyMCP card, antenatal care, Surakshit Matritva Abhiyan, maternity benefit

4 · ChildbirthJanani Suraksha Yojana, Janani Shishu Suraksha Karyakram, LaQshya, SUMAN

5 · NewbornHome visits, special newborn care units, kangaroo mother care, MAA

6 · Infant and childImmunisation, Rashtriya Bal Swasthya Karyakram, nutrition, diarrhoea, pneumonia

STEP 1 · FRAMEWORK AND TOOLS — how the system is organised

🏛️ THE FRAMEWORK

Element	Details
History	Reproductive and Child Health (RCH) programme from 1997, combining child survival, safe motherhood, family planning, abortion, and reproductive tract infection services; RCH Phase II from 2005 under the National Rural Health Mission; RCH+A in 2013 adding adolescent health; NHM covers rural and urban areas
Strategy	RMNCH+A: a continuum of care across life stages and across home, community, and facility (the 'plus' adds adolescents and linkages with nutrition, water, and sanitation)
Delivery points	Health and wellness centres (sub-centres and primary health centres), community health centres, first referral units (with caesarean and blood facilities), district hospitals, Anganwadi centres, and village health and nutrition days
Frontline workers	ASHA (incentive-based community health worker), auxiliary nurse midwife, Anganwadi worker, multipurpose worker
Tracking	MCP card (the woman's and child's health record); name-based registration of every pregnancy and child; U-WIN (digital immunisation registry with reminders and certificates)
Emergency transport	National ambulance services (108 and 102); updated guidelines standardise vehicles, staff, equipment, and digital integration
Targets	Sustainable Development Goal 3: maternal mortality under 70 per 100,000 live births by 2030 (also the Surakshit Matritva Aashwasan Roadmap 2030 target); India Newborn Action Plan: single-digit neonatal mortality and stillbirth rates by 2030 (from memory)

STEP 2 · PREGNANCY AND CHILDBIRTH — safe motherhood programmes

🤰 MATERNAL HEALTH PROGRAMMES

Programme	Details
Janani Suraksha Yojana (JSY)	Launched 12 April 2005; cash for institutional delivery. Low Performing States (Uttar Pradesh, Uttarakhand, Bihar, Jharkhand, Madhya Pradesh, Chhattisgarh, Assam, Rajasthan, Odisha, Jammu and Kashmir): all women delivering in government facilities. Rural: mother Rs 1,400, ASHA Rs 600; urban: mother Rs 1,000, ASHA Rs 400. High Performing States: below-poverty-line, Scheduled Caste and Scheduled Tribe women; rural Rs 700, urban Rs 600 for the mother (amounts as reported in secondary sources and the 2017–18 annual report; check the current order)
Janani Shishu Suraksha Karyakram (JSSK)	Launched 1 June 2011: free delivery including caesarean, drugs and consumables, diagnostics, blood, diet, and transport; extended in 2013 to antenatal and postnatal complications and to sick infants up to 1 year; reduces out-of-pocket spending
Pradhan Mantri Surakshit Matritva Abhiyan (PMSMA)	Free, comprehensive antenatal check by an obstetrician or medical officer on the 9th of every month; over 7.91 crore check-ups and over 1.24 crore high-risk pregnancies detected (as reported); follow up high-risk women with the ASHA and red-card labelling (from memory)
Pradhan Mantri Matru Vandana Yojana (PMMVY)	Ministry of Women and Child Development: Rs 5,000 for the first child in two instalments (Rs 3,000 after pregnancy registration and one antenatal check within 6 months of the last menstrual period; Rs 2,000 after birth registration and the child's vaccines up to 14 weeks); Rs 6,000 for a second child if a girl; age 19 or more; excludes regular government and public-sector employees; deadlines vary, so check the portal
LaQshya	Quality improvement of labour rooms and maternity operation theatres with national certification; 1,244 labour rooms and 917 maternity operation theatres certified by February 2026 (as reported)
Surakshit Matritva Aashwasan (SUMAN)	Assured, dignified, respectful, zero-cost care and zero denial; SUMAN Roadmap 2030 aims for maternal mortality under 70
Maternal Death Surveillance and Response	Notify, review, and act on every maternal death (see the Reproductive Morbidity and Maternal Mortality sheet)
Obstetric high-dependency and intensive care units	Critical care for the sickest women (see the Obstetric ICU sheet)

Standard antenatal contacts (from memory): at least 4 visits (first in the first trimester), tetanus–diphtheria (Td) vaccine, iron and folic acid, calcium, deworming, haemoglobin, blood pressure, urine, HIV, syphilis, and hepatitis B testing, and an ultrasound at least once

STEP 3 · NEWBORN AND CHILD HEALTH — survival and healthy growth

👶 NEWBORN AND CHILD PROGRAMMES

Programme	Details
Home-based newborn and young child care	ASHA home visits in the first 42 days (more for low-birth-weight and sick newborns) and in the first 36 months (Samagra Shishu Bal Swasthya Karyakram combines home-based newborn care and home-based young child care); danger-sign checks, breastfeeding support, and referral
Facility-based newborn care	Special newborn care units (district), newborn stabilisation units (first referral units), and newborn care corners (delivery points); 2017–18 report: 712 special newborn care units, 2,329 stabilisation units, 18,323 newborn care corners (now higher); see the Care of Premature Newborn sheet
Kangaroo mother care and MAA	Kangaroo mother care for low-birth-weight and preterm babies; MAA (Mothers' Absolute Affection) promotes breastfeeding within the first hour and exclusive breastfeeding for 6 months (from memory)
Rashtriya Bal Swasthya Karyakram (RBSK)	Screens children from birth to 18 years for the '4 Ds': birth defects, diseases, developmental delays, and deficiencies; about 30 conditions covered; Anganwadi screening at 0–6 years and school screening at 6–18 years; District Early Intervention Centres for follow-up
Nutritional Rehabilitation Centres	Facility care for children with severe acute malnutrition and medical complications; 1,148 centres in the 2017–18 report
Diarrhoea and pneumonia	ORS with zinc (Stop Diarrhoea Campaign) and SAANS (Social Awareness and Actions to Neutralise Pneumonia Successfully) (from memory)
Poshan Abhiyaan and Anganwadi services	Supplementary nutrition, growth monitoring, early childhood education, and counselling for pregnant and lactating women and children under 6 (from memory)

STEP 4 · IMMUNISATION — protect every mother and child

💉 UNIVERSAL IMMUNISATION PROGRAMME (UIP)

Age	Vaccines
Birth	BCG, oral polio vaccine (OPV) zero dose, hepatitis B birth dose
6 weeks	OPV-1, pentavalent-1, rotavirus-1, fractional inactivated polio vaccine (fIPV)-1, pneumococcal conjugate vaccine (PCV)-1
10 weeks	OPV-2, pentavalent-2, rotavirus-2
14 weeks	OPV-3, pentavalent-3, rotavirus-3, fIPV-2, PCV-2
9–12 months	Measles-rubella (MR) 1, Japanese encephalitis 1 (endemic districts), PCV booster
16–24 months	MR-2, Japanese encephalitis 2, DPT booster 1, OPV booster
5–6 years	DPT booster 2
10 and 16 years	Tetanus–diphtheria (Td)
Pregnancy	Td-1 and Td-2, or one Td booster if vaccinated within the previous 3 years

UIP began in 1985 and protects against 12 diseases; additions: inactivated polio vaccine (2015), rotavirus (2016), measles-rubella (2017), pneumococcal conjugate vaccine (2017); Mission Indradhanush (from December 2014) targets missed children and pregnant women; HPV vaccine for 14-year-old girls began on 28 February 2026 (about 1.15 crore girls); indigenous Td vaccine launched 21 February 2026 (per PIB)

📲 COVERAGE AND DIGITAL TOOLS

Full immunisation coverage was about 76% in the National Family Health Survey 5 (2019–21); the Press Information Bureau reports 98.4% in January 2026 from administrative data — the two measures differ, so quote the source

U-WIN (launched October 2024): one mobile number can register up to 10 people; 12 languages; by March 2026 it had registered about 11.87 crore children and 3.96 crore pregnant women (as reported)

eVIN (Electronic Vaccine Intelligence Network) tracks vaccine stock and cold-chain temperature in real time

Vaccines are free at sub-centres, primary and community health centres, hospitals, and outreach sessions; ASHAs and Anganwadi workers mobilise families

STEP 5 · ADOLESCENTS AND FAMILY PLANNING — before and between pregnancies

🧑‍🎓 ADOLESCENT HEALTH, ANAEMIA AND FAMILY PLANNING

Programme	Details
Rashtriya Kishor Swasthya Karyakram (RKSK)	Adolescent health: nutrition, weekly iron and folic acid supplementation, sexual and reproductive health, mental health, injuries, substance misuse, and non-communicable disease; adolescent-friendly health clinics; peer educators (the Saathiya initiative)
Anaemia Mukt Bharat	Prevent and treat anaemia in children, adolescents, women of reproductive age, and pregnant and lactating women; strategy revised from 6×6×6 to 7×7×7 (adding low-birth-weight infants, 'eating right', and digital tracking); 'Test, Treat, Talk, Track'
HPV vaccination	Free quadrivalent vaccine for 14-year-old girls at government facilities from 28 February 2026; cervical cancer is the second commonest cancer in Indian women with about 80,000 new cases and over 42,000 deaths a year (as reported); screening reaches under 2% of women aged 30 to 49
Contraceptive basket	Condoms, oral pills, emergency contraception (within 72 hours), the injectable DMPA, copper intrauterine devices (Cu-T 380A, effective for up to 10 years), female sterilisation, and vasectomy; ASHAs deliver condoms and pills to the doorstep
Sterilisation and indemnity	Family Planning Indemnity Scheme and standards (see the Female Sterilisation sheet)
Safe abortion	Medical Termination of Pregnancy Act services free in government facilities (see the medicolegal sheet)

STEP 6 · SOCIAL PROTECTION — cash, insurance and leave

💰 CASH, INSURANCE AND LEAVE

Scheme	Details
Maternity Benefit Act (2017 amendment)	26 weeks' paid leave for the first two children for women in covered establishments (from memory)
Ayushman Bharat — PM-JAY	Cashless hospital cover for eligible families (Rs 5 lakh per family per year, from memory); covers many obstetric and newborn procedures
State schemes	Odisha has its own maternal cash-transfer scheme (MAMATA) and state health-assurance schemes; check the current state notification and how they fit with PMMVY (from memory)
Social benefits	Public distribution system, take-home rations at Anganwadi centres, and school meals support nutrition

STEP 7 · USING THE PROGRAMMES IN PRACTICE — match the problem to the scheme

🧭 WHAT TO INVOKE WHEN

Situation	Programme or action
Woman cannot afford delivery or a caesarean	Janani Shishu Suraksha Karyakram: free care and no charges
No transport in labour or for a sick infant	Call 108 or 102; Janani Shishu Suraksha Karyakram transport
Pregnant woman in the first trimester	Register on the MCP card, enrol for PMMVY, advise the 9th-of-the-month check
High-risk pregnancy	Flag it, plan delivery at a first referral unit or higher centre, track with the ASHA
Sick or low-birth-weight newborn	Special newborn care unit, kangaroo mother care, home-based newborn care visits
Child with a birth defect or developmental delay	Rashtriya Bal Swasthya Karyakram and the District Early Intervention Centre
Missed vaccines	U-WIN catch-up at the nearest session; Mission Indradhanush
Anaemic woman or adolescent	Anaemia Mukt Bharat: test, treat, talk, track
Maternal death	Notify and review under Maternal Death Surveillance and Response

⚠️ COMMON PITFALLS

Asking families to buy drugs, blood, or tests that are free

Not registering the pregnancy or child, so cash benefits and vaccine reminders are missed

Quoting old cash amounts or deadlines — orders change; confirm with the current notification

Poor follow-up of high-risk women and of discharged newborns

Missing vaccines at birth (BCG, polio zero dose, hepatitis B) and in pregnancy (Td)

Treating schemes as paperwork instead of a safety net for the woman and child

Memory Aid

JANANI

Six pillars of government reproductive and child health programmes.

J

JSY and JSSK — cash for delivery; free delivery, drugs, blood, diet, and transport

A

Antenatal care — MCP card, the 9th-of-the-month check, PMMVY, high-risk follow-up

N

Newborn care — home visits, special newborn care units, kangaroo mother care

A

Anaemia and nutrition — Anaemia Mukt Bharat, Poshan Abhiyaan, Anganwadi

N

Needle protection — UIP, Td in pregnancy, U-WIN, Mission Indradhanush, HPV

I

Inclusive adolescent and family planning services — RKSK, contraception, safe abortion

Remember: register, refer, and never deny a free entitlement.

Swaraj Hospital & Research Institute · Department of Obstetrics & Gynaecology, Bolangir, Odisha

Clinician-facing summary. Read in this session from published sources, not from the programme guidelines themselves: the Press Information Bureau feature of 17 March 2026 (immunisation schedule, Universal Immunisation Programme history and additions, U-WIN, Mission Indradhanush, the HPV and Td launches); the Ministry of Health and Family Welfare Annual Report 2017–18, chapter 23 (Janani Shishu Suraksha Karyakram, Rashtriya Bal Swasthya Karyakram, unit counts, 2017–18 Janani Suraksha Yojana packages); and secondary education and news pages (Janani Suraksha Yojana state list and current packages, Pradhan Mantri Matru Vandana Yojana, Pradhan Mantri Surakshit Matritva Abhiyan and LaQshya figures, Anaemia Mukt Bharat, HPV burden). The Odisha scheme, Maternity Benefit Act, Ayushman Bharat cover, antenatal package, MAA, SAANS, and the India Newborn Action Plan target are from memory. Amounts, deadlines, and coverage figures change often, so confirm with the current National Health Mission and Ministry orders; thresholds, intervals and regimens vary between guidelines — check current official notifications before quoting entitlements to patients.