Community I* Level Interventions For Improving Maternal, Neonatal And Child Health: A Training Tool Kit
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Community I*
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For Improving Maternal, Neonatal
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Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
DESIGN, PLANNING
AND IMPLEMENTATION
OF THE SUKSHEMA PROJECT
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
I*
DESIGN, PLANNING
AND IMPLEMENTATION
OFTHESUKSHEMA PROJECT
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sukshema
Improved Maternal, Newborn & Quid Heald)
wrwo Wtp
—
ACRONYMS.
7
SESSIONS
Introduction
1.1 Background of the Sukshema Project
8
2.
Gaps in MNCH services..............................................
2.1 Gaps in awareness and gender..........................
2.2 Gaps in coverage and outreach..........................
2.3 Gaps in roles and responsibilities......................
2.4 Gaps in coordination............................................
2.5 Gaps in community support and engagement
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3.
Intervention theory and approach
13
Sukshema's focus on a MNCH continuum of care
14
5.
Sukshema's technical intervention package
15
6.
Solution categories and levers..................................
6.1 Primary and innovations solutions........................
6.2 Sukshema's community intervention objectives
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16.
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7.
Sukshema's tools to improve MNCH services
17
8.
Implementation activities.........................
8.1 Implementation strategy.....................
8.2 Development of materials.................
8.3 Development of the Tool Kit............
8.4 Training of Trainers (ToT)....................
8.5 Roll out and reaction to the training
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9.
Tool Kit Outline.......................
9.1 Planning for the training ..
9.2 Registration process........
9.3 The seven modules..........
9.4 Tool Kit training schedule
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10. Facilitation approach and process..................
10.1 Qualities of a facilitator..............................
10.2 Roles and capacities of a facilitator........
10.3 Facilitation skills...........................................
10.4 Preparing for the training..........................
10.4.1 Preparation..........................................
10.4.2 Process management........................
10.4.3 Resource management.....................
10.4.4 Human relations management......
10.5 Energizers......................................................
10.6 Recap sessions and evaluation activities
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11. Getting started...............................
11.1 Doorway to successful training
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ACRONYMS
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ANC
ARI
ARS
ASHA
AWW
BCC
BPL
CBO
CDL
DOH
EDD
FLW
FP
FRU
GoK
HBMNC
IEC
IMR
IPC
J HA
JSY
JHA
KHPT
MDG
MMR
MNCH
NGO
NRHM
PHC
PNC
PRI
RP
SBA
SC
SC/ST
SCM
SHRC
SHS
SRS
TBA
TT
VHW
VHSNC
Ante Natal Care
Acute Respiratory Infection
Arogya Raksha Samitis
Accredited Social Health Activist
Anganwadi Worker
Behaviour Change Communication
Below Poverty Line
Community Based Organization
Community Demand List (CDL1) Tool
Department of Health
Expected Date of Delivery
Frontline Health Worker
Family Planning
First Referral Unit
Government of Karnataka
Home Based Maternal Newborn Care
Information, Education, Communication
Infant Mortality Rate
Inter Personal Communication
Junior Female Health Assistant
Janani Suraksha Yojana
Junior Female Health Assistant
Karnataka Health Promotion Trust
UN Millennium Development Goals
Maternal Mortality Rate
Maternal, Newborn and Child Health
Non-Government Organization
National Rural Health Mission
Primary Health Centre
Post-natal Care
Panchayat Raj Institution
Resource Person
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Supportive Community Monitoring
State Health Resource Centre
State Health Society
Sample Registration System
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health Worker
Village Health and Sanitation Nutrition Committee
Design, Planning and Implementation of the Sukshema Project
7
1. INTRODUCTION
1.1 BACKGROUND OF THE SUKSHEMA
PROJECT
India launched its National Rural Health Mission
(NRHM) in April 2005 to tackle the high burden of
maternal, neonatal and child morbidity and mortality
in India’s rural populations. Key aspects of the NRHM
are its enormous scale, its focus on extending services to
the rural poor, and its inherent flexibility for introducing
innovative approaches for improving health system
responses to improve maternal, newborn and child
health (MNCH) outcomes.
Congruent with the NRHM’s objectives and approaches,
the Bill >& Melinda Gates Foundations (the Foundation’s)
Maternal and Neonatal Health (MNH) Strategy seeks
to improve MNCH outcomes in the world’s poorest
regions by catalysing health system responses to ensure
that critical, proven interventions during pregnancy
and in the neonatal period reach underserved
populations. While the NRHM provides a broad canvas
with processes and funding mechanisms to achieve
Sukshema project districts
8
health goals, the Foundation’s strategy focuses on a
critical technical intervention package to enhance the
performance of health systems. The Foundation has
awarded funds to the University of Manitoba and the
Karnataka Health Promotion Trust (KHPT) to support
the Government of Karnataka (GoK) to develop and
implement strategies to improve MNCH in alignment
with the NRHM’s objectives and approaches.
The Sukshema project was designed and planned to
focus on improving the availability, accessibility, quality,
utilization and coverage of critical MNCH interventions
among the rural poor in eight priority districts in
northern Karnataka: Bagalkot, Bellary, Bidar, Bijapur,
Gulbarga, Koppal, Raichur and Yadgir.
The goal of the Sukshema project is to support the
GoK to improve MNCH outcomes in rural populations
through the development and adoption of effective
operational and health system approaches within the
NRHM. To achieve this goal, the project is designed to
integrate and align key aspects of the Foundation’s MNH
strategy with the NRHM’s health system infrastructure
and mechanisms in the eight project districts, with the
following four key objectives:
1.
Enable expanded availability and accessibility of
critical MNCH interventions for rural populations.
2. Enable improvement in the quality of MNCH
services for rural populations.
3. Enable expanded utilization and population
coverage of critical MNCH services for rural
populations.
4. Facilitate identification and consistent adoption
of best practices and innovations arising from the
project at the state and national levels.
The project had two phases: planning and
implementation. The 12 month planning phase was
intended to: 1) carry out various assessments related
to project objectives; 2) design implementation models
for improving availability, quality and coverage of the
interventions; and 3) develop health system responses
necessary to implement the models. The 48 month
implementation phase focuses on supporting the
NRHM to implement and assess strategies for delivering
the intervention package, and translating knowledge
developed through the project for wider dissemination,
as well as advocacy and adoption of key elements by the
NRHM at state and national levels.
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
2. GAPS IN MNCH
SERVICES
The assessments carried out under the project
have indicated that critical gaps in the availability,
accessibility, quality, utilization and coverage of MNCH
services exist at three levels: health system, facility and
community, level. The latest available data on maternal
mortality rate (MMR) is for the period 2010-12. During
this period, the MMR of India was 178 per 100,000
live births. The latest infant mortality rate (IMR) for
the country as per the Sample Registration System
(SRS) 2012 was 42 per 1000 live births, which had
decreased from 47 in 2ol0 and from 50 in 2009. The
Maternal Mortality Estimation Inter-Agency Group
- WHO,UNICEF,UNFPA, World Bank report titled
“Trends in Maternal Mortality: 1990 to 2010” ranked
India 126 out of 180 countries in ascending order of
MMR. As per the report published by UNICEF in
2012 titled “Committing to Child Survival; A Promise
Renewed” India ranked 45 out of 195 countries in the
world in descending order of IMR. Although much
effort has gone into health system strengthening, such
as enhancing the functional abilities of staff nurses,
providing job aids and checklists to simplify their work,
improving the drug supply and strengthening referrals,
there are a number of gaps that still exist.
2.1 GAPS IN AWARENESS AND GENDER
Currently, there is a lack of awareness in the community
on healthy practices and available services for the
mothers and newborns through the MNCH continuum
of care. Often existing cultural practices and beliefs, and
insufficiently informed decisions, become barriers to
access of MNCH services. The findings from Sukshema’s
assessment of community facilitators and barriers
for utilization of MNCH services have re-confirmed
that the practices related to pregnancy, delivery, and
post-natal care, as well as the decisions to seek care,
are institutionalized within the family. The elders in
the family, particularly the mothers-in-law and the
mothers, as well as the husband, play an important role
in decisions on seeking care, as well as in perpetuating
unhealthy practices. Therefore, the Sukshema project
plans to focus not only on the pregnant woman or new
mother, but to also target family members and the wider,*
community. Otherwise, its MNCH activities would only
be partially successful.
The status of women in Indian society must also be
taken into account when looking at the situation of
maternal and child health. Before pinning all the blame
on poor awareness levels among women, it is important
to look at other factors that either directly or indirectly
affect a woman’s health during the MNCH continuum
of care stages. In rural India the family members have
a bearing on all aspects of an individual’s life. Members
of the family, especially the male and the elderly,
generally make decisions for the rest of the family. These
decisions are usually based on “family values” and what
is considered socially “appropriate”, rather than based on
individual needs and facts.
For example, several cultural and traditional beliefs that
exist in rural and even some pockets of urban India
drive women and families to make decisions that are
more often detrimental to the health of the women and
the child. There are prevalent myths and misconceptions
about pregnancy, delivery, new mothers and child care.
The preference for sons leads to repeated abortions and
poor birth spacing. The belief that hard work during
pregnancy will help prevent caesarean deliveries. The
belief that more blood loss after child birth means more
body impurities are expunged, thus keeping the body
slim after delivery. The belief that the first breast milk
(actually very rich in colostrum), is impure because
of its yellow colour, so the newborn should not be fed **
with it. All of these misconceptions have been culturally
intertwined within families and are repeatedly reiterated
by the elders in the family.
Studies have shown that the father, mother, husband,
in-laws, grandfather and grandmother, living together
in an extended family situation, exert a tremendous
influence on the pregnant woman, leaving her with little
option but to succumb to the pressure and submit to
their decisions.
Design, Planning and Implementation of the Sukshema Project
9
Addressing awareness about the larger gender realities is
essential to build a holistic perspective of MNCH. Thus,
the Sukshema project plans to offer an intensive training
that brings front line health workers (FLWs) together
and leads them through a process of critical thinking,
reflection and evaluation of issues around MNCH and
gender-social perspectives.
2.2 GAPS IN COVERAGE AND OUTREACH
In the MNCH continuum of care, existing data indicates
that the coverage of target populations is poor and
inequitable. More than half of all maternal and newborn
deaths occur during childbirth and the first few days of
a baby’s life; this is also the period when health coverage
is lowest. An effective MNCH continuum of care focuses
on two dimensions in its provision:
• Time; recognizing the need to ensure essential
services for mothers and children during pregnancy,
childbirth, the postpartum period, infancy and early
childhood.
• Place; or linking the delivery of essential services
in a primary health care system that integrates
home, community, outreach and facility based care.
The impetus for this focus is the recognition that
gaps in care are often most prevalent at the locations
- the households and community - where care is
most required.
Available data indicates that the coverage of target
populations for MNCH services is poor and inequitable:
there are unreached populations for many services,
and those who are reached do not receive a complete
package of services through the MNCH continuum
of care from antenatal to child care. For instance, as
per the DLHS (District Level Household Survey) for
northern Karnataka, while 74% of pregnant women
received tetanus toxoid (TT) injections, fewer than 27%
received the full set of ANC visits. Similarly, only 52% of
recently delivered women received a postnatal care visit
within 48 hours of delivery. A large proportion of certain
populations, particularly migrants, and those belonging
to scheduled castes and tribes, seem to be left out of the
registers maintained at the Sub Centres (SCs). While the
proportion of institutional deliveries has risen in recent
years, only a small proportion of mothers stay for 48
hours after delivery in facilities. As per the state Health
Management Information Systems (HMIS), only 38%
of women delivering in institutions during August 2010
-July 2011 stayed for at least 48 hours after delivery.
and track the beneficiaries of maternal and new born
services. Currently there is no standard format for
planning services. A critical gap in outreach includes
unreached target populations such as migrants, poor
families, those belonging to the Scheduled Caste/
Scheduled Tribe (SC/ ST) community. Very often these
marginalised groups are left out due to social and
cultural factors along with the practical difficulties in
reaching these groups. Even if they are targeted, not all
services reach them due to lack of individual-centred
assessments and lack of focus on prioritizing hard-toreach populations. This renders the MNCH programme
inequitable.
Another gap is those who are reached receive
incomplete package of services that puts mothers and
infants at risk of morbidity and mortality, increasing
their vulnerability. This is because poor planning and
monitoring, especially at the individual level, affects
outreach for service delivery. Gaps caused by lack of
tools and job aids for planning effective outreach, poor
communication skills and absence of clear concise key
messages affect the health seeking behaviour among
the target populations, resulting in poor access of all
services across the MNCH continuum of care. All of
these challenges point to the need for building capacity
to provide services.
Another important factor is the underlying role of the
larger community to be aware of the issues and barriers
to maternal and child health at the village level and
exercise responsibility and accountability to reduce
maternal and infant deaths. The process of ensuring
increased coverage should provide ample space for
the community to participate and develop ownership.
Effective outreach therefore is a result of skilled and well
trained FLWs equipped with the needed tools and job
aids, and an aware community that supports and owns
this effort
2.3 GAPS IN ROLES AND RESPONSIBILITIES
Community outreach activities in providing MNCH
care services is of utmost importance. Strong outreach
means increased coverage for services and improvement
in the demand and the accessibility of MNCH services.
At the community level the FLWS, including the Junior
Female Health Assistant (JHA), the Accredited Social
Health Activist (ASHA), and the Anganwadi Worker
(AWW) all play a vital role in providing the health
services related to pregnant women, nursing mothers
and newborns.
In order to ensure that services are rendered at the right
time and place, there needs to be a plan to maintain
10 Community Level interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Department of Women and Child
Development (DWCD), Karnataka Govt.
Health department, Karnataka Govt.
I
'
S
JHA (Junior Health Assistant- Female)
I
Anganwadi worker
Total no: 12,275
Total no: 2,007
ASHA (Accredited Social Health Activist)
Total no: 8,270
T
FRONTLINE HEALTH WORKERS (FLWs)
Total no: 22, 552 in all 8 Sukshema districts
In Karnataka State, the term Junior Female Health
Assistant (JHA) has now replaced the role of the
Auxiliary Nurse Midwife (ANM). The JHA plays a
multitude of roles including:
• Informing women about the side effects of
immunisation, importance of breast feeding,
maternal and new born care at home, permanent and
temporary family planning options
• Enrolling pregnant women and filling in “Thayi” card
during the registration
• Explaining immunisation process to new mothers and
giving TT injections
• Measuring the blood pressure of pregnant woman,
checking the weight of the child after delivery and
giving iron tablets 5 months after delivery
• Educating about nutritious food, hygiene and
institutional delivery to the woman
« Providing Information to the pregnant woman about
the benefits of scanning
• Providing information about the government
schemes available to 1st and 2nd delivery mothers
• Referring pregnant women with complications to
higher care centres
• Conduct deliveries in case of emergencies in the sub
centres
• Conducting home visits
• Educating the family about home based care needed
for the new bom baby, especially with low birth
weight
• Providing information to nursing mothers about
precautions to be taken to avoid infection
• Collecting blood samples if the pregnant woman or
the nursing mother has a fever
p
The Accredited Social Health Activist (ASHAs), being
members from the neighbourhood, are the community
resources to facilitate a positive change in awareness and
practices around maternal and child health through the
continuum of care. They have been described as activists
in the community who will create awareness on health
and its social determinants and mobilize the community
towards local health planning and increased utilization
and accountability of the existing health services.
Their tasks include outreach activities such as
motivating women to give birth in hospitals, linking
them to MNCH services provided by the government,
mobilizing children to attend immunization clinics,
encouraging family planning (e.g. surgical sterilization),
treating basic illness and injuries with first aid, keeping
demographic records and participating in activities
to improve village sanitation. ASHAs also serve as
an important communication channel between the
healthcare system and rural communities.
Although the ASHAs undergo a fairly comprehensive
initial training about their functions, in practice, their
focus has been on referrals, or bringing people to
services - particularly for institutional delivery. There
has been very little emphasis and expectation from
them as a change agent - in influencing awareness and
practices related to critical MNCH services. There are
L*'
no easy-to-use interpersonal communication materials
and job-aids to facilitate ASHAs in performing the role
of a change agent. There also is a need for focus on the
critical MNCH issues around which the ASHAs need to
work with the families to improve their awareness and
practices.
Design, Planning and Implementation of the Sukshema Project 11
The Anganwadi Worker (AWW), delivering services
through the Department of Women and Child
Development, focus on health education promotion
highlighting nutrition. They are tasked with:
• Mobilizing pregnant women for immunisation camps
• Encouraging and motivate people to seek institutional
delivery and adopt family planning methods
• Registering newborns
• Conducting home visit to give nutritional advice to
pregnant and nursing mothers of children 6 months
to 3 years old
« Conducting mother's meeting and nutrition camps
to provide health education and distribute nutritious
food for pregnant women , nursing mothers and
children 6 months to 3 years old
• Keeping track of the childrens weight and refer
malnutrition cases to higher care centres
• Enrolling malnourished children in the
Bhagyalakshmi scheme (only for the BPL card
holders)
• Identifying sick children and refer them to higher
care center for treatment under the “Bala Sanjeevini”
program
• Conducting Balavikasa Samithi meetings
• Identifying healthy children and showcasing them in
baby shows
2.4 GAPS IN COORDINATION
Although all three FEW groups were supposed to be
working towards the same goal - improving MNCH one of the key gaps that was noted in the field was the
lack of coordination between them. This gap affected
their relationship with each other as well as that with the
community. In the field these three groups had created
barriers between themselves, making sure they did not
mix either personally or through their work. Rather than
having the community needs drive them, it was their
own department guidelines and personal differences that
guided them. For example, age difference, varying work
experiences, caste differences and being employed by
different Government Departments kept these workers
from being united on the ground for a common cause.
Although each group does have designated roles,
focusing on collaborating and coordinating their roles
would allow them to get more satisfaction out of their
work. If they worked together they could channel their
energy and efforts towards finding effective strategies
to challenges and sharing burdens. For any program to
be successful it is crucial that the stakeholders involved
are sensitive to and supportive of each other. Therefore,
while each group of FLWs has to take care of their
own responsibilities, they also need to understand the
responsibilities of other groups and to build effective
coordination on the ground. This could create an
enabling work environment for all FLWs. Working
together in a coordinated manner can also help them
take a united stand when faced with hurdles like nonsupportive community members and families.
2.5 GAPS IN COMMUNITY SUPPORT AND
ENGAGEMENT
Engaging the community in planning and monitoring
health service delivery is central to enhancing the
availability, accessibility, quality and use of the public
health system. The NRHM has positioned community
ownership as central to its strategy, primarily through
the Village Health, Sanitation and Nutrition Committee
(VHSNC). The VHSNCs are village-level bodies
comprised of key stakeholders who serve as a forum for
village planning and monitoring. VHSNCs were formed
to ensure that no section of the village community
is excluded from services; to prepare a village health
plan to suit local realities and necessities; to provide
monitoring and oversight to all village health activities;
and to ensure that untied funds are appropriately used
for improving maternal and neonatal health in the
village. Facilitative monitoring and support to FLWs
through VHSNCs to better MNCH outcomes is a feature
of strengthening community accountability. As well
as the VHSNCs, in Karnataka, Arogya Raksha Samitis
(ARS) have been established as sub-committees of the
Public Health Planning and Monitoring Committees to
provide community oversight at the facility level.
A review of the existing community based bodies,
their current functions, and the existing gaps and
challenges suggest poor knowledge about health
systems and procedures among the members, poor
understanding of their role in the community, especially
with regard to MNCH, and an absence of tools to
help VHSNC members to systematically support the
monitoring processed. Additionally, there was a felt
need to change the perception of monitoring among
the VHSNC members of being authoritative, probing
and supervisory, to being supportive, participatory and
facilitating.
Under Sukshema, as part of the community
interventions, the Supportive Community Monitoring
(SCM) intervention was designed, piloted and
implemented in order to address the above gaps. This
intervention helps sensitize and strengthen the existing
community structures as envisaged by NRHM, which
would in strengthens community monitoring at the
village levels. The SCM intervention contributes to this
process by assisting the VHSNCs to systematically and
12 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
joint responsibility of improving MNCH outcomes.
Every village has VHSNCs in place as per the mandate
of the NRHM. To form an SCM a six-member
group should be selected and approved that includes
the VHSNC president, representatives of FLWs,
representatives from womens and youth groups, and
people from the SC/ST community. In Karnataka, the
NRHM has also engaged non-government organisations
(NGOs) in building the capacities of these community
structures. KHPT is one of these NGOs, working in
Bagalkot and Koppal to build VHSNC capacity through
the Samartha project.
periodically assess and reflect on the key MNCH and
health related indicators and processes around service
delivery in their areas. This in turn contributes to their
planning and ownership of the health system delivery
processes on the ground.
Another key expected outcome form this process is
to bridge the widening gaps between the community
structures and the health service delivery mechanisms
at the village level The Sukshema project believes that
improved supportive community monitoring could
lead to building mutual trust between the FLWs and the
community representatives, and encourage them to take
3. INTERVENTION
THEORY AND
APPROACH
In line with the Foundation’s MNH strategy, the Sukshema project has prioritized technical interventions and solution
levers. Through piloting and field testing of innovations and adaptations, and scale up at all levels, the Sukshema
project aims to improve MNCH outcomes in northern Karnataka. The broad intervention approaches and strategies
are represented in Figure 1.
LEVELS OF CHANGE
OBJECTIVES OF CHANGE
Health Systems
(infrastructure, staff,
equipments, drugs,
supplies, incentive^ •
Improve availability/
accessibility
Facility
(Sub-centers and
Primary Health
Centers)
i
Improve
data quality
and use
Community
(Village Health
and Sanitation
. -1
Committees, Arogya
Raksha Samitis)
PROCESS OF CHANGE
—
Pildt/field test
technical interventions
and solutions
Improve
quality
Critical MNCH
interventions
F
Prioritize technical
interventions and
solution levers
■
Diffuse/scale up
innovations from pilot
areas to rest of the
project districts
Increase utilization/
coverage
I
J
I
KNOWLEDGE TRANSLATION
r
KARNATAKA
|
INDIA
Figure 1: Sukshema intervention approach and strategy
4. SUKSHEMA'S
FOCUS ON A MNCH
CONTINUUM OF
CARE
(where abortion is legal); and improved childhood nutri
tion. Sukshema’s interventions and the location of the
intervention (facility, community or both), are indicated
in Figure 2.
The MNCH continuum of care extends from pre-pregnancy to the postnatal period and up to 12 months of
age for the infant and up to 5 years for a child. However,
extra focus has been given to interventions at the time
of delivery and the period from 48 hours to 1 week after
birth. This period represents a critical time where more
than half of maternal and neonatal deaths occur. Addi
tionally, the success of the Janani Suraksha Yojana (JSY)
scheme in northern Karnataka has led to an increase in
facility-based deliveries predominantly at primary health
centres (PHCs), which has overburdened facilities and
compromised quality of delivery and neonatal care. With
over 80% of pregnant women now delivering in facilities,
the project has also prioritized interventions that specifi
cally target improved MNCH care at the facility level.
The need to strengthen existing critical skilled birth and
postnatal care services at PHC level is essential and very
timely given the local context and shift towards facility
based delivery; failure to do so will result in a critical lost
opportunity to improve MNCH.
MNCH represents one of the greatest areas of global
inequities in health, with disparities both across and
within regions. Each year far too many women and
infants die from causes that are both preventable and
easily treatable. Yet effective interventions exist that can
be delivered through well-functioning health systems,
along the MNCH continuum of care. These interven
tions can significantly reduce maternal and neonatal
morbidity and mortality.
These interventions can be broadly grouped into the fol
lowing main categories: comprehensive family planning;
skilled health care for women and newborns (antenatal
care, quality delivery care with a skilled birth attendant,
emergency obstetrics and neonatal care, postnatal care
and essential newborn care); safe abortion services
>
BIRTH
>
>
POST-NATAL
■
... .................. ;
'
zQuality delivery of
•complete package of
•
ANC
Community based
rapid diagnostic tests
for infections
Quality management
of normal/routine
deliveries
Build and enhance
BEmOC competencies
at PHC level
tor Preterm labour/
■ ' birth
Basic neon3tsi
resuscitation
■■■I
to 48 hour hospital stay
CHILD
5. SUKSHEMA'S
TECHNICAL
INTERVENTION
PACKAGE
A key to the Sukshema project is the selection of a criti
cal technical intervention package that is relevant to
the local context and is based on strong evidence. This
technical intervention package forms the basis for the
improvements in MNCH that the project wishes to at
tain, and represents the “what” of the project. It consists
of two types of interventions:
1.
2.
Primary - interventions that have been prioritized to
be included in the Sukshema project due to: (a) strong
evidence; (b) need for the intervention in project
districts driven by current levels of utilization and
coverage; and (c) fit with the Foundation's priorities;
and
Innovations - interventions that are either new to
Karnataka or need to be adapted to the local context
Objectives of
change
Critical gaps/Barriers
Solution
categories
Health
systems
Enable expanded
availability and
accessibility of critical
MNCH interventions
for rural populations
• Inadequate distribution of facilities and
staff across populations and geographies
• Inadequate availability of, supplies and
equipments
• Inadequate access for the rural poor
to specialist services for delivery and
newborn care
1. Influencing policy
and planning
2. Improving
capabilities of and
tools for health
providers
Facility
Enable improvement
in the quality of
MNCH services for
rural populations
• Weak clinical, managerial, and
administrative competencies inhibit
the ability to deliver critical health
interventions and services
3. Engaging
community in
planning and
monitoring
Community
Enable expanded
utilization and
population coverage
of critical MNCH
services for rural
populations
• Limited awareness of available services
and incentives for maternal and newborn
health
• Cultural practices and beliefs that
determine health seeking behaviour
• Poor community engagement in
exercising rights to quality services
• Poor coverage of target populations
for MNCH services- unreached target
populations and reached by incomplete
package of services
Improve data quality
and use
• Poor data quality and analytical skills
weaken programme management
delivery and improvement
Improved full vaccination
coverage
Community based
integrated maternal
and neonatal carq
assessment and protocol
tool
Management of sepsis
and LBW
Community
Facility
The technical interventions that make up the critical
package were selected because they represent a group
of proven and innovative interventions that collectively
address the most pressing gaps in current MNCH
services in northern Karnataka. Therefore, these inter
ventions are likely to produce the greatest improvement
in MNCH outcomes in the area. Table 2 shows the level
of change expected, the objective of the change and the
critical gaps that fit within the solution categories.
Levels of
change
Maternal postpartum
; counseling, assessment,
stabilization and referral
Incentives for frontline
workers for postnatal
visits
• Strong evidence of effectiveness in improving MNCH
outcomes (morbidity and mortality);
• Need (poor coverage) for the intervention;
• Intervention a priority for NRHM and the GoK;
• Intervention a priority for the Foundation;
• Minimal duplication of the intervention with other
programmes; and
• Feasible and scalable implementation in the local
context.
TABLE 2: CRITICAL GAPS/BARRIERS AND SOLUTION CATEGORIES
/
Basic newborn care
After examination and discussion of the evidence from
baseline surveys and secondary data, a list of possible
technical interventions was prepared. The technical
interventions were prioritized for inclusion if they met
all of the following criteria:
Cross
cutting
I'
4. Shaping demand
5. Strengthening data
management and use
Both levels
Figure 2: Interventions across continuum of care
Design, Planning and Implementation^/ the Sukshema Project 15
it
6.2 SUKSHEMA'S COMMUNITY
INTERVENTION OBJECTIVES
6. SOLUTION
CATEGORIES AND
LEVERS
Sukshema community interventions are designed and
implemented with the following objectives:
6.1 PRIMARY AND INNOVATIONS
SOLUTIONS
1.
The solution levers represent the “how” of the package,
i.e. these are the activities that need to be undertaken for
effective implementation of the technical package. These
solution levers address critical gaps and have impacts
across several project objectives and technical foci. Two
types of solution levers are envisaged:
2.
Primary - solution levers that have been shown
effective in India or elsewhere, that can be readily
integrated into existing platforms and taken to scale
quickly.
Innovations - solution levers that have less evidence
to support their effectiveness, and that would need
to be applied in a significantly novel way, or that
involve a fundamentally different operating model.
These solution levers would need targeted creation of
infrastructure or new capabilities and would need to
be pilot tested for feasibility of implementation and/or
effectiveness.
Within each solution category, specific solution levers have been identified as key. The coloured areas in Table 3
represent community interventions, many of which are innovations.
TABLE 3: SPECIFIC SOLUTION LEVERS
1. Influendng
policy and
planning
Illi
(D
Facilitation of
policy changes that
respond to critical
issues related to
infrastructure,
staff, supplies and
financial incentives
(2)
Improvement
of public-private
partnerships
2. Improving
3. Improving
management
quality of care
and delivery of
at birth and
outreach
immediate
services and
postpartum care
shaping demand
at facilities
(3)
On-site mentoring
for improved clinical
care and service
delivery
(4)
Micro-planning tools
and methods to
ASHAs and ANMs to
improve coverage
(5)
Integrated maternal
and newborn
management
tools to improve
i
identification and
i
actions for postnatal j
danger signs
4. Strengthening
accountability
5. Strengthening
data
' '
management
and use
(7)
Community
monitoring tools for
VHSCs
I
(6)
Family focussed
communication tools
and materials to
use with families to
influence awareness
and practices
16 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
1. To increase thefrequency and quality of
interactions between beneficiaries and FLWs.
2. To ensure that all pregnant and postpartum women,
newborns and infants enter into the MNCH care
continuum.
3. To ensure that all pregnant and postpartum women,
newborns and infants continue in the MNCH care
continuum.
4. Enhance participation of community-level
structures in supporting and monitoring the
utilization and coverage of MNCH services.
J
sW
SF*. . j
7. SUKSHEMA'S
TOOLS TO
IMPROVE MNCH
SERVICES
(8)
Development and
implementation
of data quality
controls and audits
(9)
Development and
implementation of
protocols for data
analysis and use for
programme review,
planning and
problem solving
A critical gap in monitoring and planning coverage for services through the MNCH continuum of care was that there
were no tools and aids available for FLWs to map and track pregnant women and children. The existing tools available ;,
did not provide an integrated approach to the health of the mother and the baby and there was no focus on the FLWs
to be change agents to encourage improved MNCH practices in the community. There were also no tools that could
aid FLWs to screen for danger signs among mothers and newborns and to quickly link them to skilled care when
needed.
To improve the coverage for routine maternal and newborn services, particularly for the SC/ST and poor families, the
Sukshema project designed interventions and developed tools and aids in consultation with the FLWs to help make
these interventions successful.
First of all, family-focused communication (FFC) is an intervention to improve the engagement and communication
with community members, be it pregnant women, families or children. It aims to build rapport and trust so that the
knowledge shared by the FLWs can be translated into positive behaviour change among the community members.
For this to happen, every FLW needs to be trained on personality development and communication skills including
convincing, persuading and positive authority over her target audience to build enabling environments. FFC Tools
and behaviour change communication (BCC) materials include a diary, calendar with story-line messages on birth
planning and emergency preparedness, and reminder cards - a set of cards with key messages used during home
visits. Module 4 gives more details about the FFC Tools.
Design, Planning and Implementation of the Sukshema Project 17
Secondly, an intervention designed to improve the enumeration and tracking of pregnant women was developed to
improve planning for outreach services and coverage. The Community Demand List (CDL) Tool is a visual aid that
replaces multiple registers, reduces manual entry of columns and is easy to carry. Using this tool, the ASHA will be
able to list all the target population (pregnant women, recently delivered women and the newborns) in her allotted
geographic area in a particular month, and track the same during pregnancy, delivery, 42 days post-delivery and nine
months of immunization of the newborn. It will identify gaps in reaching target populations to help her plan activi
ties accordingly, while being able to prioritise services due to selected risk and vulnerability factors such as age, caste,
poverty level, migration, gravida, complications in previous pregnancies, and previous place of delivery. Module 5
gives more details about the CDL Tool.
The third intervention and tool was designed to improve comprehensive home based care through identification
of complications and knowledge about suitable remedial measures. The Home Based Maternal and Newborn Care
(HBMNC) Tool can improve the quality of interactions between the ASHA and the pregnant/recently delivered
woman and the newborn during the antenatal and postnatal periods. It helps ASH/Vs remember to seek certain infor
mation from the mother about herself or the newborn. The HBMNC Tool captures the health status of the pregnant/
nursing mother in the same format as the health centre, which helps the ASHA to track important care services.
Module 6 gives more details about the HBMNC Tool.
Lastly, the supportive community monitoring (SCM) intervention and tool addresses the following gaps: lack of com
munity platforms for planning and monitoring village health programs; the negative perception that monitoring is
authoritative, probing and directive; the lack of ownership and accountability of the village health programs in general
and MNCH issues in particular; and the widening gap between needy communities and the health service system.
The Supportive Community Monitoring (SCM) Tool focuses on the VHSNC members and encourages discussion
with ASHAs, AWWs, and community representatives. It also highlights the need for VHSNC members to reflect on
the gaps in support they provide to FLWs focused on MNCH, availability of health staff, sub-populations that need
support, and community practices and beliefs. Module 7 gives more details about the SCM Tool.
8. IMPLEMENTATION
ACTIVITIES
______________________________
8.1 IMPLEMENTATION STRATEGY
The Sukshema projects community intervention
implementation strategy included field testing of the
tools and methods in two of the projects districts,
including Bagalkot and Koppal, and then scaling-up
to the remaining six districts of Bellary, Bidar, Bijapur,
Gulbarga, Raichur and Yadgir, based on the learning.
This also included leveraging support from the GoK
departments for rolling out these tools and methods.
The recruitment and training of Resource Persons
(RPs) to support the FLWs was also piloted in Bagalkot
and Koppal, before being rolled out throughout the
Sukshema project area. The RPs included the technical
leads and managers at the central office, district program
speciahsts, and district monitoring and evaluation (M &
E) specialists.
The three-day induction training covered the following
topics: introduction to Sukshema’s goals, objectives,
technical interventions and solution levers; services
to be provided throughout the MNCH continuum
of care; service delivery mechanisms; and proposed
interventions at the community level for the FLWs and
community structures. The training method included
lectures, group work and role plays.
There was a second 3-day training that took place during
June 2012 for FLWs on all the components of FCC. The
topics covered included: perspectives on community
outreach; improving basic communication skills among
FLWs; achieving coordination among all the FLWs at the
village level; and skills to facilitate SC level meetings and
coordination among functionaries.
of FLWs, ASHA mentors, VHSNC/Panchayat members,
RPs, sub-district coordinators, district coordinators, the
project technical leads and managers, district program
specialists and district M&E specialists. The workshop
participants reviewed the tools and then drafted the
guidelines for use of these tools. •
Selected members of FLWs were trained on how to use
the tools and the initial reaction was encouraging. For
example, after using the tools in the field for a few days,
the ASHAs reported that the ETT tool was beginning
to bring positive results with improved planning and
outreach. One ASHA in Bagalkot reported that, "This
is the simplest tool that we have ever used and it has
idrastically simplified our recording process and the
burden of referring to innumerable registers has been
reduced”. Another ASHA from Koppal stated, "One
single woman can be tracked throughout her service cycle
using this single tool. It helps us to plan our monthly home
visits and also track migrant women, which had been a
big challenge.”
After piloting the HBMNC Tool and the SCM Tool,
the following voices reflected their usefulness. Another
ASHA from Koppal said, “This training helped me to
gain more clarity on the importance of prioritizing
messages when we do home visits. Earlier, during each
of my visits, I found myself giving the woman the same
messages. This training has helped me to use it as a
checklist to see if the right messages are reaching the
women for the particular stage they are in.” A VHSNC
member from Bagalkot noted that, “Before the training
we all had heard about monitoring, but we had no idea
about what exactly we had to monitor to improve on
MNCH in our village. The training gave us clarity on
how and what to monitor.”
8.2 DEVELOPMENT OF MATERIALS
8.3 DEVELOPING THE TOOL KIT
The Sukshema project organized field testing of the
developed tools and processes that would empower the
FLWS to strengthen the MNCH activities in the target
district. A three day tool development consultation
workshop was organized that included a selected group
The aim of the Tool Kit was to develop a participatory
resource that would increase the availability, accessibility,
quality, utilization and coverage of critical MNCH
continuum of care interventions focused on rural poor
Design, Planning and Implementation of the Sukshema Project 19
pregnant women and their family members to improve
services. Existing MNCH materials, developed through
GoK programs and other development initiatives across
the country, were critically reviewed by MNCH experts,
KHPT staff and FLWS in the target communities.
The materials adapted for inclusion in the modules of
the Sukshema project’s Tool Kit were then critically
evaluated for relevance, applicability and usefulness to
ensure that the information would be extremely relevant
in the field. Then these materials were piloted.
8.4 TRAINING OF TRAINERS (TOT)
Qualified individuals who could act as Trainer of
Trainers (ToTs) were identified. This group of facilitators
was a mix of mid-level and senior staff who had a good
understanding of the context of the field and the issues
faced by FLWs. They also had experience in sharing
information and transferring skills. They were trained
on all six modules using the same participatory methods
that they would then pass on to the FLW facilitators.
FLWs who had good communication skills, a deep ’
understanding of the context in the field, adequate
knowledge of MNCH issues, and high confidence levels
were chose to be facilitators.
8.5 ROLL OUT AND REACTION TO THE
TRAINING
A plan to rollout the Sukshema project’s Tool Kit was
implemented and the results were equally as positive as
with the individual tools. The FLWs were appreciative
of the training opportunity, which brought all the FLWs
together under one roof for the first time. The training
served as an opportunity for them to understand each
other’s roles and challenges and encouraged mutual
support for their work and their personal challenges.
The training also dealt with socio-cultural issues around
MNCH that helped build perspectives of the team. The
following quotations highlight the positive reactions:
I
BF))) "/n my 30 years of experience I have not
attended a training of this kind. This is the first time that
alt three FLWs: ASHAs, JHAs and AWWs, were brought
under the same roof for training. It was an excellent
thing to do. We always worked in isolation and we
carried our department wise differences into our work.
This training helped us break that unhealthy practice"
-JHA, Bagalkot.
“Previously, when I did home visits, my concentration
was only on pregnant women and nursing mothers.
At the end of this training I understood that family
members also should be counselled closely as they
have a great influence on women and their decisions
during pregnancy and delivery" - ASHA, Bagalkot.
"We had very'poor perception concerning MNCH
issues. The training helped us see that we are working
for women and not for any particular government
department. We are now able to identify with the issues
and struggles of v/omen and give them support and
advice" - AWW, Koppal.
The RPs not only train, but support and mentor the FLWs. It is expected that the newly trained and motivated FLWs
will in turn build the capacities of the ASHAs working under different PHCs to help them improve the quality of
their performance in providing MNCH continuum of care services to pregnant women, their families, and their
community.
The Tool Kit should be used after recruiting the RPs. Each RP is in charge of one PHC which comprises of about
16-20 villages. The training will be conducted at the PHC or the SC level with approximately 20 to 30 participants in ■ ‘
each training session. Local training venues for both residential and non-residential trainings should be identified
to ensure easy travel and provide a comfortable stay for the participants to maximize their utilization of time. Travel
Allowance (TA)/ Daily Allowance (DA) for the participating FLWs can be mutually agreed upon after discussion with
the concerned GoK departments.
All the modules have been field tested with a variety of participants with varying literacy levels. The ToTs have
ensured that the facilitators know how to present the information in each session so that all participants can absorb it
verbally, or through the use of participatory facilitation methods. The role of the facilitator will be to determine what
level the participants are at, and what information, and in which form, to deliver in the training. It is envisaged that
medical staff, for example Medical Officers, either in the project staff or within the GoK’s health department, could be
leveraged as resource people for technical sessions.
9.2 REGISTRATION PROCESS
Before the training starts for any of the seven modules, ensure that every participant registers himself or herself. Each
participant must enter their name, designation, place of work, contact number and signature in a register provided at
the entrance to the training hall. Once the participant finishes entering these details, the facilitator or an assistant will
distribute the training kit with a note pad, pen, and handouts of the reading material to the participants and guide
them inside the halL The facilitators need to ensure that all the participants complete the registration process.
9.3 THE SEVEN MODULES
The Community Level Interventions for Improving Maternal, Neonatal and Child Health Tool Kit is a series of seven
modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Health Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Based Maternal and Newborn Care
Module 7: Supportive Community Monitoring
9. TOOL KIT OUTLINE
■
■
***
9.1 PLANNING FOR THE TRAINING
The Tool Kit was specifically developed to strengthen the capacity of the FLWs in the eight priority districts of the
Sukshema project in northern Karnataka. The project has envisaged a new workforce of local level workers designated
as Resource Persons (RPs). The RPs are trained on all modules in the Tool Kit and function as ToTs for the FLWs.
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Module 1: Design, Planning and Implementation of the Sukshema Project
is aimed at Resource Persons (RPs) and other developmental professionals working in the area of Maternal Neonatal
and Child Health (MNCH). It gives the background of the Sukshema project and its intervention theory and approach
to MNCH in reducing the infant mortality rate (IMR) and the maternal mortality rate (MMR) in eight northern districts
of Karnataka. It highlights the main strategies in the project aimed at enhancing the community's engagement in
improving outreach, increasing demand for MNCH services and building accountability and transparency in the service
delivery systems in the field. The module explains the participatory development of tools, approaches, and training of
trainers (ToTs) processes. For facilitators it gives an overview of sessions included in the seven modules of the Tool Kit,
including a suggested time frame. It also sets the stage for training with guidance on facilitation, including preparation,
process management, resource management, and human relations. The section 'Getting Started: Doorway to Successful
Training' should always be used to start a training workshop: initially if covering all modules at one time, or as a refresher
if modules are scheduled over a period of time. It contains a set plan of sessions that set the stage for the workshop
activities and logistics, covering welcome, introductions, objectives, hopes and fears, and ground rules.
Module 2: Core Concepts of Maternal Neonatal and Child Health
trains the resource persons (RPs) employed by the Sukshema project on technical information on the maternal neonatal
and child health (MNCH) continuum of care. This continuum includes four stages: Antenatal care - care during pregnancy;
Intra-natal care - care during the delivery and first two hours after the delivery; Post-natal care (mother and newborn) care during the first 42 days; and Child care - care of the child up to year 5. The training sessions details critical issues in
the MNCH continuum of care's four stages and lays the foundation and understanding of related concepts and medical
Design, Planning and Implementation of the Sukshema Project 21
terminologies among the front line health workers (FLWs), including the Junior Female Health Assistant (JHA), the
Accredited Social Health Activist (ASHA), and the Anganwadi Worker (AWW).
Module 3: Sukshema's Community Level Interventions
is aimed at Resource Persons (RPs) to provide an overview of the community level interventions planned under the
Sukshema project. Enhancing communication is highlighted in the family focused communication intervention and the
enumeration and tracking intervention seeks to bridge the gaps that occur in the Maternal Neonatal and Child Health
(MNCH) continuum of care. Two other tools are introduced: one to improve the quality of interaction during home based
care, the Home Based Maternal Newborn Care (HBMNC) Tool; and the other to enhance planning, accountability and
monitoring of health service delivery through the Supportive Community Monitoring (SCM) Tool. This module also gives
participants the opportunity to clarity roles and responsibilities of a number of field level workers in the Sukshema project
and in the Government of Karnataka (GoK) health service.
Module 4: Communication and Collaborative Skills for Front Line Health Workers
focuses on the Junior Female Health Assistant (JHA), the Accredited Social Health Activist (ASHA), and the Anganwadi
Worker
the three groups that are key front line health workers (FLWs) in the Sukshema's project. The module
will lead them through sessions that will enhance their understanding about: gender and social issues related to the
acceptability and access to Maternal Neonatal and Child Health (MNCH) continuum of care services; the importance
of focussing on the family as a unit for bringing about desired changes related to MNCH practices; and addressing the
gaps in coordination among FLWs in the field. Overall the module aims to improve communication skills during outreach
and interactions with the pregnant woman, her family and the community through Family Focused Communication (FFC)
Tools, which can help FLWs value themselves and their work, both when working independently or in a group.
Module 5: Improving the Enumeration and Tracking Process
enhances the capacities of the Accredited Social Health Activist (ASHA) and the Junior Female Health Assistant (JHA)
to identify, register and track all pregnant women in her area across the Maternal Neonatal and Child Health (MNCH)
continuum of care. One of the key challenges identified in the field was the absence of effective enumeration and
tracking tools. This led to gaps in the number of pregnant women accessing the full extent of services throughout
the MNCH continuum of care service. The Community Demand List (CDL) Tool was developed specifically to identify
which women in a specific area should be given what services and when the next service is due. The practical hands-on
introduction to this tool should improve utilization of all MNCH services by all pregnant or recently delivered women and
their newborns.
9.4 TOOL KIT TRAINING SCHEDULE
The Tool Kit modules have been envisaged, designed, piloted and piloted in the filed as an interrelated package of
information. For effective results it is recommended that each module is presented as part of the entire Took Kit, and
not in isolation. However, although a detailed outline of the Modules and the Sessions is presented below, there is
scope for facilitators to adapt this training depending on the profile, background, literacy level of the participants and
overall context of the training environment.
The proposed training schedule is as follows:
Module 1
Design, Planning and Implementation of the Sukshema Project
1. Introduction
1.1 Background of the Sukshema Project
2. Gaps in MNCH services
2.1 Gaps in awareness and gender
2.2 Gaps in coverage and outreach
2.3 Gaps in roles and responsibilities
2.4 Gaps in coordination 2.5 Gaps in community support and engagement
3. Intervention theory and approach
4. Sukshema's focus on a MNCH continuum of care
5. Sukshema's’technical intervention package
'
Module 6: Home Based Maternal and Newborn Care
is a training module for Accredited Social Health Activists (ASHAs) developed to enhance their communication skills and
quality of homes visits. Once the ASHAs complete the enumeration and tracking of their area, they have the responsibility
to ensure that all services reach the beneficiaries. It is the ASHAs' prerogative to reach out to the mother and child
through home visits to deliver information, create awareness, identify symptoms of ri^k early and make timely referrals.
In this context the quality of home visits conducted by the ASHAs need to result in bridging the information gap to a
greater extent and bring about the expected results mentioned above. This module aims to specifically improve the
capacities and the skills of the ASHA to conduct effective home visits by using the Home Based Maternal Newborn Care
(HBMNC) Tool.
Module 7: Supportive Community Monitoring (SCM)
aims to develop the capacity of the members of the Village Health and Sanitation Nutrition Committee (VHSNC). These
members are tasked with providing support to the front line health workers (FLWs) in their village, monitor service access
and delivery, as well as participate and share responsibility to improve the Maternal Neonatal and Child Health (MNCH)
outcomes and general health status of their village. The module is intended to help the VHSNC members understand
the concept of supportive community monitoring as opposed to authoritative supervision. It aims to help VHSNC
representatives engage the community in planning and monitoring health service delivery to enhance the availability,
accessibility, quality and use of the public health system. Through the formation of a smaller group of active Supportive
Community Monitoring (SCM) members who are trained to carry out specific roles and responsibilities, this can be
achieved. These SCM members will be trained to use a SCM Tool that allows them to conduct a regular joint reflection
process, leading to community monitoring and evaluation of health delivery systems on the ground.
■
6. Solution categories and levers
6.1 Primary and innovations solutions
6.2 Sukshema's community intervention objectives
7. Sukshema's Tools to improve MNCH services
8. Implementation activities
8.1 Implementation strategy
8.2 Develo’pment of materials
8.3 Development of the Tool Kit
8.4 Training of Trainers (ToT)
8.5 Roll out and reaction to the training
9. Tool Kit Outline
9.1 Planning for the training
9.2 Registration process
9.3 The seven modules
9.4 Took Kit training schedule
10. Facilitation approach and process
10.1 Qualities of a facilitator
10.2 Roles and capacities of a facilitator
10.3 Facilitation skills
10.4 Preparing for the training
10.4.1 Preparation
10.4.2 Process management
10.4.3 Resource management
10.4.4 Human relations management
10.5 Energizers
; .J-": -.-; ■:..
22 Cpmr'iunity
-VAntiShs for Improvihg Msterris
A TratMng Tool Kit
„
Design, Planning and Implementation of the Sukshema Project 23
Session 4: Understanding women and their status in the society
10.6 Recap sessions and evaluation activities
11. Getting started
11.1 Doorway to successful training
Welcome participants
Introductions of participants
Objectives of the workshop
Hopes and fears
Ground rules for the workshop
3 hours
Module 2
Core Concepts of Maternal, Neonatal and Child Health
1 hour 30 minutes
Session 5: Power walk
1 hour 30 minutes
Session 6: Developing different perspectives
45 minutes
Session 7: Maternal and child care: Then and now '
1 hour
Session 8: Coordination and collaboration in the field
4 hours 30 minutes
(for all 6 activities)
Session 9: Training evaluation and feedback
30 minutes
Total time for Module 4
16 hours 45 minutes
Module 5
Improving the Enumeration and Tracking Process
Session 1: Understanding MNCH continuum of care
2 hours 30 minutes
Session 2: Antenatal care (ANC)
2 hours 30 minutes
Session 1: Community outreach for MNCH continuum of care
1 hour
Session 3: Delivery / intra-natal care
3 hours
Session 2: Critical role of job aids and Tools in outreach
1 hour
Session 4: Post-natal care (PNC)
3 hours
Session 3: Challenges in outreach
1 hour
Session 5: Child care
3 hours
Session 4: Introduction & practice of the Community Demand List (CDLI)Tool
2 hours
Session 6: Critical issues in MNCH continuum of care
1 hour
Session 7: Post-test and training evaluation and feedback
30 minutes
Total time for Module 2
15 hours 30 minutes
Module 3
Sukshema’s Community Level Interventions
Session 5: Introduction and use of the Community Demand List (CDL2) Tool
1 hour 30 minutes
Seston 6: Vulnerable groups: identification and problem solving
2 hours
Session 7: Training evaluation and feedback
30 minutes
Total time for Module 5
9 hours
Module 6
Home Based Maternal and Newborn Care
Session 1: Understanding Sukshema's community level interventions
1 hour
Session 2: Enhancing communication and coordination using family
focused communication
2 hours
Session 3: The Arogya Mantap - providing space for collaboration and
discussion
Session 1: Maternal, infant and child mortality
30 mins
Session 2: Stages of service delivery
1 hour
30 minutes
Session 3: Front line health workers: providing MNCH continuum of care
services
1 hour
Session 4: Bridging gaps in MNCH continuum of care through enumeration
and tracking
1.5 hours
Session 4: The HBMNC Tookproviding quality MNCH continuum of care
services
1 hour
Session 5: Improving the quality of interaction in providing home based
maternal, neonatal and child care
1 hour
Session 5: Using the HBMNC Tool - Section 1 Identification
1 hour
Session 6: Providing ANC services
1 hour
Session 7: Using the HBMNC Tool - Section 2 ANC
1 hour
Session 8: Providing Intra-nata! (Delivery) care services
1 hour
Session 9: Using the HBMNC Tool - Section 3 Delivery
1 hour
Session 6: Enhancing accountability through supportive community
monitoring
2 hours
Session 7: Staff structure, roles and responsibilities and drawing-up an action
plan
1 hour
Session 8: Training evaluation and feedback
30 minutes
Session 10: Providing PNC services
1 hour
Total time for Module 3
9 hours 30 minutes
Session11: Using the HBMNC Tool - Section 4 PNC
1 hour
Session 12: PNC home visits: Health education and counselling
1 hour
Module 4
Communication and Collaborative Skills for Front Line Health Workers
Session 1: Underlying causes of mother and infant mortality
1 hour 30 minutes
Session 2: Understanding family focused communication (FFC)
1 hour 30 minutes
Session 3: Fnhancing communication skills: five activities for FLWs
4 hours (for alf 5 activities)
24 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
Session 13: Introducing IEC materials
30 minutes
Session 14: Practical use of the HBMNC Tool
2 hours
Session 15: Training evaluation and feedback
30 minutes
Total time for Module 6
14 hours 30 minutes
Design, Planning and Implementation of the Sukshema Project 25
■ .
/
...l
improving the MNCH continuum of
j>;
Module 7
care services
Supportive Community Monitoring
Session 1: Sharing knowledge and purpose
Session 2: Critical MNCH issues
Trust builder: Need to build trust
between participants and yourself,
30 minutes
"
as well as between different
participants and groups who may
have different viewpoints and
priorities, such as the FLWs.
1 hour
Session 3: Understanding the importance of the SCMT
1 hour
Session 4: Modalities, role and responsibilities of the SCMT
1 hour
Session 5: Understanding the SCM Tool
2 hours
Session 6: Selection of a SCMT convener
45 minutes
Capacities of a facilitator
Session 7: Responsibilities of the SCMT members
30 minutes
Session 8: Drawing up a SCMT action plan
1 hour 15 minutes
Session 9: Quiz and training evaluation and feedback
30 minutes
Total time for Module 7
Knowledge and skills:
•
8 hours 30 minutes
•
‘•''■I
J*
10. FACILITATION
APPROACH AND
PROCESS
10.1 QUALITIES OF A
FACILITATOR
Almost anyone can become a
facilitator as long as they have
the ability to acquire the right
attitudes, behaviours, knowledge,
and facilitation skills, and be able
to apply these confidently in a
workshop focused on MNCH.
Ideally, facilitators should:
• Speak the local language of the
participants
• Understand the culture of the
participants and the social
context
• Be willing and interested in
learning from the participants
• Have a basic knowledge of
MNCH services and activities
• Be committed to improving
the MNCH continuum of care
services
• Have an open attitude to using
participatory training activities/
tools to fully involve and engage
participants
• Be able to plan, monitor, and
evaluate the training process, or
be able to acquire these skills
M*
environment.
Attitudes and Behaviours:
Perhaps the most important
quality of a facilitator is that they
acknowledge the importance
and benefit of mobilizing the
participants so that they want
to develop the knowledge and
skills necessary to carry out their
job duties.
• A facilitator should also commit
themselves to the principles
of participation so each of the
participants can fully explore
their role in providing quality
MNCH services.
• Facilitators should model
attitudes and behaviours that
are empowering rather than
disempowering, enabling rather
than dominating, participatory
rather than excluding, flexible
rather than rigid.
• There are many factors
that encourage or inhibit a
participant from fully taking part
in workshop activities, such as
language, experience speaking
in public, and experience related
to the topic.
• Some FLWs have attended
very few training programs.
Even if they have attended
a workshop/meeting, it
probably would have been
•
10.2 ROLES ANDCAPACITIES
OF A FACILITATOR
Roles of a facilitator
A facilitator needs to perform
several roles effectively and
efficiently:
Planner: Need to be familiar with
the topic, session plans, materials
t and training process in advance to
ensure that the objective of each
training session is achieved.
Advocate for participation: Need
to encourage and elicit active
participation of all participants to
build their capacity in all areas of
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Knowledge of MNCH and basic
services. Facilitators should
be able to provide basic and
accurate information about the
current situation for specific
populations and how to improve
outreach and increase demand
for services in the field.
Knowledge of a range of
examples to illustrate the
relevant social context and
how to build accountability
and transparency in the MNCH
service delivery systems in the
field to create a strengthened
a traditional situation where
there would have been
minimum opportunity
for participation in the
process. The current training
program is designed to be
participatory in its approach.
• Power relations related to
people's social and economic
position in the community can
also have an effect and may
affect a person's capacity to
fully speak up and out during
a workshop.
• To correct and balance such
situations, a facilitator must
create an environment that is
conducive to open.discussion,
sharing of experiences, and
asking and answering personal
questions. He or she must
create an atmosphere in which
everyone feels respected, safe,
and encouraged to share their
true views, and to listen to,
respect and interact with others
who might have diverging views.
• To ensure learning:
• Use the local language as
much as possible. Introduce
any medical terms in English,
but explain them using the
local terminologies.
• Consolidate the learning
at the end of each activity,
session or day. Encourage
participants to describe what
happened, how they felt,
or reacted to it; how does it
relate to their work; and how
they may apply it in future.
10.3
•
•
tone of voice.
Asks questions to show a desire
said by paying attention to a
speaker's body language and
•
to understand.
Summarizes and re-phrases
the discussions to check on
an understanding of what
has been said and asks for
feedback.
Effective questioning: This is
essential in training or facilitating
as effective questioning increases
people’s participation in group
discussions and encourages their
involvement in problem-solving. In
effective questioning, the person
asking questions:
•
•
•
•
Asks open ended questions,
for example using the six key
“helper" questions: Why?
What? When? Where? Who?
and How?
Asks probing questions by
following up people's answers
with further questions that
look deeper into the issue.
Continually asking "but
why...?* is useful for doing this.
Asks clarifying questions to
ensure they have understood.
This can be done by re-wording
a previous question.
Asks questions about personal
points of view by asking about
how people feel and not just
about what they know.
FACILITATION SKILLS
Active listening: This means more
than just listening. It means helping
people feel that they are being
heard and understood. Active
listening encourages participation
and a more open communication of
experiences, thoughts, and feelings.
In active listening, the person
listening:
•
•
not be appropriate until some
trust has been established.
Listens to how things are
Uses body language to show
interest and understanding. In
most cultures this will include
nodding the head and turning
the body to face the person
speaking.
Uses facial expression to show
interest and reflect on what
is being said. It may include
looking directly at the person
speaking. In some cultures
such direct eye contact may
Facilitating group discussion: This
increases the participation of all
group members and ensures that a
range of community perspectives
and interests are included. Good
facilitation skills help to improve
the quality of group discussion
and problem-solving. Facilitators
can also help build consensus
where necessary, and encourage
participation and ownership of
MNCH issues. When facilitating
group discussions facilitators:
•
•
•
Introduce themselves and the
purpose and nature of the
session to participants.
Ask each person in the group
to introduce themselves to
each other.
Ensure that everyone is
comfortable and can see and
hear each other.
Design, Planning and Implementation of the Sukshema Project 27
•
•
Agree with the participants on
the aims of the session and
how much time is available.
Agree on 'ground rules' with
participants, including the
need to respect opinions and
confidentiality.
Agree with the participants
on how the discussion will
be recorded and what will
happen to this record at
the end of the session.
Remember: this is 'their'
process, not yours - allowing
them to keep the drawings
and diagrams from the
session increases their sense
of ownership in the process.
However, taking notes and
keeping copies may prove
useful later.
• Help the participants to
remain focused on the agreed
aims of the session.
• Enable all group members to
contribute to the discussion
by paying attention to who
is dominating discussions
and who is not contributing
(remember that people have
different reasons for being
quiet-they may be thinking
deeply).
• Summarize the main points
of the session and any action
points that have been agreed
•
•
upon.
Thank the participants for
their time and contributions
and, if appropriate, agree on
a time and place for a further
meeting.
Parking lot: Introduce the concept of
a 'parking lot'. Put a blank sheet or flip
chart paper titled 'Parking Lot' at the
front of the training room. Encourage
participants to use the sheet to write/
post issues and questions that arise
during group discussion or in any
module sessions. The parking lot list
allows space for other participants
to discuss any listed issue during
tea breaks, or lunch. Alternatively,
information can be sought from other
external experts or project heads and
shared with all during morning recap
time or afternoon evaluation periods.
Ensure that all questions raised in the
parking lot are answered during the
training programme.
Using participatory methods and
tools: Avoid didactic teaching
(teacher-centred, telling facts, and
assuming right and wrong answers).
complex situations and gain
insights on how these types
of incidences can be avoided
in future. Multiple cases on
similar situations are used
Instead, become familiar with
participatory forms of learning. Some
suggestions for including participatory
methods and tools are:
to expose the participants
to different dimensions of
the situation/ problem and
learn new concepts. However,
most situations have complex
backgrounds and it is not
expected that participants
will be able to assess all
the factors that could have
contributed to a particular
situation. The purpose of
a case study is to generate
probing questions about what
might have happened and to
find an empowering solution.
For introductory sessions, when
participants are just becoming
acquainted, they experience
tension, doubts and suspicions.
A new place, new environment
and new faces could inhibit their
participation. So be sure to create
a supportive, fun and encouraging
training environment. Although
participants possibly come from the
same background and geographical
area, and may speak the same
language, they may only have
a nodding familiarity with one
another, and may show reluctance
to acknowledge individual
relationships. Therefore, a positive
beginning of the training is vital
for both participants as well as
facilitators. It aims to bring out the
background of all the participants;
their interests, hobbies and talents.
Without reducing this session
to mere formality for eliciting
the names and contacts of the
participants, the facilitator should
find an innovative way to conduct
self-introductions so that everyone
feels like they know each other and
has a better understanding of the
other participants. In Session 5:
Getting Started, there are a number
of suggested activities to start off
each module.
For awareness-generating sessions
introduce the topic, then use role
plays, small group discussion, case
studies, simulation, and learning
games to provide an opportunity
to experience the concept, share
reactions and observations,
reflect upon implications, and
consequences, discuss patterns
and dynamics, develop practical
and conceptual understanding and
apply it to real life situations.
•
For knowledge-based sessions start
by introducing the topic, find out
what the current level of knowledge
is using the brainstorming
technique, then use mini-lectures to
present the information, backed up
with audio-visual aids such as flip
charts or PowerPoint presentations.
Follow-up with an exercise to
practice the knowledge that was
presented, then provide a handout
to recap all information.
•
Using PowerPoint presentations
• Use PowerPoint slides for
a better visual impact and
as a reference point and
as a base for creating a
better understanding in the
participants. But do not limit
yourself to what is presented
in the slides. Explain the
medical terms that are
used in the presentation
thoroughly, and ensure that
the participants understand
the pie charts or any other
•
how that point is important
for them to understand in the
context of their responsibility
to motivate the ASHAs and
Using a case study
• Note that a case study is used
to offer an opportunity to
participants to understand
and appreciate different
MNCH issues and to facilitate
discussions that help them
reflect and analyse real life
actions, events, episodes and
experiences based on their
own experiences. A case
study can be used to identify
what went wrong in the
statistics.
Add as much extra
information as possible to
help participants understand
JHAs to provide better service
and ensure that the maximum
number of pregnant women
access the complete package
of MNCH care services.
For skills-based sessions explain
and describe the skills first, followed
by a demonstration, and then
hands-on practice time, either in
28 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
pairs or small groups, followed
by group discussion of success/
challenges with the process.
10.4 PREPARING FOR THE
TRAINING
Before the training note that prior
preparation is essential for effective
facilitation. Note the four main
aspects involved in conducting
a training program: preparation,
process management, resource
management, and human relations
management.
10.4.1 PREPARATION
Give yourself sufficient time to
prepare for the workshop. Besides
referring to the training materials,
also take time to browse through
relevant books, previous reports and
articles to strengthen facilitation.
Engage in research to keep you up
to date with current issues linked
to MNCH. A background study of
a specific area where the Sukshema
project operates in could lead to an
awareness of existing gaps.
Be prepared for different skill
levels of participants. Enlist the
help of more proficient or literate
participants to help those who
are slower or who cannot write. If
none of the participants can write,
conduct the activity verbally and use
pictorial representations or symbols
to list their expectations.
how you would have facilitated the
session in order to improve it and
note the time keeping strategies and
how to keep participants bn track’.
In some sessions that use a ‘mini
lecture’ as a facilitation methodology,
a facilitator ‘script’ is provided and
the text is italicized and indented.
Make sure you have read the
background material on the topic so
you will be prepared to answer any
questions from the participants.
The facilitator should prepare
materials and resources needed
for each session well ahead of
time. When you see that there is a
PowerPoint Presentation (PPP) listed
in the training materials, then a PPP
can be prepared using the reading
material in the annexures of the Tool
Kit’s Modules or the Information
Guides in Module 6. Other materials
to prepare might include flip charts,
posters and handouts.
Each training session follows the
same format and includes the
following information:
•
•
•
•
Objectives: What the facilitator
hopes to achieve by the end of
each session.
Methodology: Teaching
approaches and techniques used.
Duration: Length of time for each
session
Training materials: Materials that
the facilitator will use during the
session
Tips for facilitators: Gives extra
information to help the facilitator
have a successful teaching
experience. These notes could
include extra information on
the session topic, reflection on
how the session might proceed
or what could be the potential
questions/concerns that are
likely to be asked by a particular
audience and suggestions for
replies
• Process: Step-by-step instructions
on how to implement activities
and run sessions.
•
10.4.2 PROCESS
MANAGEMENT
Before the workshop the facilitator
should read the entire module
thoroughly to see how each session
flows into the next and how all the
activities are linked together to
achieve the overall aim. If possible,
conduct a small mock training
program before the real workshop
starts. Or, try to attend other
training programs conducted by
other facilitators. Make a note of
To manage time, do not drag any
session beyond the time allotted
for it unless absolutely necessary.
Frequently check to make sure the
time schedule is being followed.
If there is a lag in following the
(
schedule, ask for participants
support in getting back on track
with the schedule and the topic. Use
the “parking lot” to write and post
issues that need to be considered
later and not during the particular
session.
10.4.3 RESOURCE
MANAGEMENT
In good time before the workshop
starts make sure all the logistical
arrangements have been taken
care of. Confirm an adequate
training venue, accommodation,
and food. Prior to the training
make an observational visit to
the venue to know more about
the available facilities. If you find
something lacking, you can bring
it to the attention of the organizers.
If you need any aides or assistants,
make prior arrangements for
their presence and also ensure
task allocation well in advance. If
any assistant facilitators or guest
speakers are needed for any of the
sessions, invite them early enough
so they can plan and confirm their
schedules.
10.4.4 HUMAN RELATIONS
MANAGEMENT
Be aware that you will be the focus
of attention during the training
and be aware of your gestures
and general conduct. During the
training period, it is very important
to get sufficient rest and sleep. Do
not let problems or worries affect
your peace of mind. Keep away
from other work pressures and
mentally fortify yourself to focus
on the scheduled program. Begin
the session with confidence and self
belief.
Starting the training program on a
Design, Planning and Implementation of the Sukshema Project 29
Number of
S. No | Energizer/game
a relaxed and positive note is an
important first step. Many of the
participants will have little or no
previous experience of having
attended any training program
or workshop. Therefore it is only
natural that they might be anxious
or unsettled. Training programs
are usually arranged in a secluded
place to keep the participants from
getting distracted. This means that
the participants have to travel to
get to the training site. The journey
and the unfamiliar surroundings
of the venue will probably add to
their uneasiness. Therefore, it is
essential that the participants must
be in a proper frame of mind to be
able to participate actively in the
training sessions. They should be
given time to refresh themselves
physically and to prepare themselves
mentally. The facilitators should
strive to create a warm, cordial and
relaxed environment so that the
participants can feel at ease with
their surroundings and with each
other. This is just as important as
the actual training that will follow.
Interacting and building rapport
with co-facilitators, Sukshema
project staff and the participants as
much as possible will prove very
useful during the workshop.
Focus on building rapport with the
participants by:
•
•
•
•
•
Respecting participants' local
knowledge and encouraging
them to participate actively
in small groups and make
presentations.
Acknowledging the value of the
contribution by each participant.
Listening carefully to what
participants say and responding
to questions, observations and
remarks in a positive tone.
Accepting even incomplete
ideas and trying to develop
the ideas further, or asking for
clarification.
Not pretending to know the
answer of a particular question
if you do not. Be frank and
tell participants that you will
get back to them with more
information.
•
•
•
•
Being alert to the possibilities
of problems arising in the
groups and being prepared to
deal with them. Do not allow
one participant to dominate
the discussion, or interrupt
it. Address this clearly, but
without hurting the dominating
participant. You might say: '"Let's
give an opportunity to someone
who has not spoken yet".
Not becoming defensive, or
ignoring the participant who
interrupts. Instead, acknowledge
the value of their input, but
request them to keep their
interruptions to the minimum,
in the interest of the group.
Suggest that the issues they
raise could be discussed at
length during lunch, or tea
break, or once the session has
ended.
Avoiding a judgmental attitude.
Establishing fresh rapport with
the participants before starting
a new session if each session is
handled by different facilitators.
Dancing index Finger
Ask participants to stand in a circle.
The facilitator will tell the group
to do as she does and say what
she says. She will then lift up the
right hand and draw attention to
the index finger by folding the
remaining fingers. Now twist and
turn the index finger and tell the
group that the finger is dancing.
The entire group will follow suit
to the accompaniment of the
thakadimi-thakajanu tune and
others will provide the chorus.
Next she will unfold the thumb
and tell the group that the thumb
is also dancing with the index
fingers. This should be imitated by
i the group, again accompanied by
singing of the thakadimi-thakajanu
tune. Follow on with the left hand,
first with the index finger and then
the thumb joining in. After the
group follows suit, the thumbs
and index fingers of both hands
should be dancing. Gradually let
the body dance to the rhythm of the
thakadimi-thakajanu tune.
1.
Rhythmic Claps
Rhythmic Claps
As a relaxation exercise, this can be
used to prepare the participants for
the sessions, or it can be used for
calling the participants attention
after a break, or to bring silence
whenever the proceedings become
too noisy. Begin clapping after
saying, "OK one, two, three clap".
The group will begin by clapping
their hands twice followed by three
continuous claps and repeat the
latter three times. Conclude with
two short claps: (Tuk tuk- tuk tuk
tuk; Tuk tuk- tuk tuk tuk; Tuk tuk- tuk
tuk tuk; Tuk tuk!)
Who is Your Favourite?
The participants will stand in a
circle and each of them will draw a
smaller circle around themselves.
One participant must volunteer
to stand in the middle of the
large circle while the facilitator
takes her place in the outer circle.
The facilitator must now ask the
i participant in the middle the
question, "Who is your favourite?"
The participant must choose her
favourite by indicating something
worn by other participants. For
example, she can say, "Those
wearing watches are my favourite.'',
and all those participants wearing
watches must change their place
and go into someone else's place.
Other favourites could include
red saris and glass bangles. Each
time, one participant will be left
without a vacant spot and will
assume the role of the facilitator in
the middle to continue the game.
Encourage participants to be quick
in thinking and responding. If chairs
are available they may be used for
participants to play the game while
■ seated instead of standing.
Rani's Choice
Invite one of the participants to
come forward and declare her for
the role of the Rani or Queen. The
facilitator will act as the Minister
to the Rani. Draw a fairly large
30 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Time
participants
required
This can be used to prepare the participants for the
The entire
5 minutes
sessions, or it can be used for calling the participants
attention after a break, or to bring silence whenever
the proceedings become too noisy.
group
2.
Dancing Index
Finger
This can be used to break the monotony between
sessions, or soon after lunch to enthuse the group.
30-35
10 minutes
3.
Who is Your
Favorite?
This can be used to mix the group and to break the
monotony between sessions, or soon after lunch to
enthuse the group.
30-35
10 minutes
4.
Rani's Choice
This can be used after a demanding session to
rejuvenate the group.
30-35
15 minutes
5.
Idli-vada-chutneysambar
This is most appropriate as an introductory game
to help participants get comfortable. This can be
30-35
10 minutes
used to mix the group and to break the monotony
between sessions, or soon after lunch to enthuse the
group. It also helps in the formation of small groups.
6.
Imitation Game
This can be used to form small groups, or to mix the
larger group and also to break the monotony.
30-35
10 minutes
7.
Game of Rules
This can be used to mix the group and to break the
monotony between sessions, or soon after lunch to
enthuse the group.
30-35
15 minutes
8.
Gandhi Thatha
Game
This can be used to induce laughter among the
participants and lighten the atmosphere.
30-35
5 minutes
9.
Basket on My Head
This can be used to make the participants alert and
think up ideas and names.
30-35
5 minutes
10.
Follow the Leader
This can be used to break the monotony and helps
30-35
5 minutes
10.5 ENERGIZERS
The following activities and games
can be used as energizers during
the workshop to change the tempo
of the day, keep people alert, help
all participants mix with each other
and make friends, revive interest
levels and to help keep participants
in a relaxed frame of mind. The
facilitator should always ask
everyone to participate, but stop the
game or activity while the mood is
still jovial, and make sure there is
no negative competition among the
participants. None of the energizers
below require any materials.
When to be used
the quieter participants to come out.
11.
In the River,
On the Bank
This can be used in between post lunch sessions to
energize the group.
30-35
5 minutes
12.
Number Acting
This can be used in between post lunch sessions to
energize the group.
30-35
5 minutes
13.
Catch the Color
This can be used to help the participants to get
familiar the surroundings.
30-35
5 minutes
14.
Chicken and Chimp
This can be used to get the participants physically
active and to break the monotony between sessions.
30-35
10 minutes
15.
Blind Mice
This can be used in between post lunch sessions to
30-35
5 minutes
energize the group and break the monotony.
16.
Chain Running
This can be used in between post lunch sessions to
energize the group and break the monotony.
30-35
5 minutes
17.
Dance to the Beat
This can be used to help the participants open up
30-35
5 minutes
and break the ice.
18.
What-ho,
How-much?
This can be used to form small groups, or to mix the
larger group and also to break the monotony.
30-35
5 minutes
19.
Chitty Chitty
Bang Bang
This can be used to make the participants alert and
break the monotony.
30-35
5 minutes
circle around the Rani and say
that nobody is allowed to come
inside that circle. The remaining
participants will form 4 groups.
They have to please the Rani by
bringing simple objects desired
by her and hand it over to the
Minister. Each time the Rani desires
something, the group bringing
the desired object at the earliest
will get a point. After playing the
game for a while, analyse why a
certain group got more marks
while others got less. Explain the
need for creativity combined with
intelligence. Note: Before starting
the game, the facilitator can brief
the participant playing the Queen
to start the game asking for simple
things inside the room or hall. For
example, one pink chart paper,
four black hair clips, a pair of brown
slippers and so on. Some of the
commonly desired objects may be
brought from outside the hall as
well.
Idli-vada-chutney-sambar
Divide the participants into four
groups and name the groups as
Idli, vada, chutney and sambar,
which are all types of south-lndian
food. Ask the members of each
group to hold hands and then
form a circle. Now the facilitator
narrates a story in which the names
idli, vada, chutney and sambar are
repeated randomly. Each time this
happens, the particular group while
continuing to hold hands, should
also sit down and immediately get
up. This should be repeated every
time the name of the group figures
in the narration of the story. This
exercise is continued till the ice is
broken and everyone is smiling.
Note: This doesn't have to be a fullfledged story, but can also be a spur
of the moment spiel. For example,
"My wife, children and I went to a
hotel and asked the waiter for the
menu. He told us that they had idli,
vada, chutney and sambar. My wife
ordered idli, vada, chutney and
sambar. My son ordered for two
idlis, one vada and chutney, and
my daughter ordered three vadas,
but refused the idlis and asked
only for the sambar, but not the
chutney, while I ordered two idlis
and chutney."
Imitation Game
The participants will form a circle
and the facilitator will count off
each participant from 1 - 6 giving
each a name of an animal or a bird.
Tell all the participants to start
moving around the room and to
imitate the cries and movements
of the animals or birds they have
been named after. For example,
if it is fish, the participants must
imitate swimming; in case of frogs,
the participants will jump and so
on. Now the participants will be
asked find a partner belonging
to the same group of animals or
birds. For example, the facilitator
will announce that all frogs must
form themselves into pairs and
participants with that name will
jump like frogs towards other frogs
and become pairs. Similarly the
facilitator can ask different kinds
of birds to form pairs and so on.
Ensure that participants imitate the
appropriate cries and movements
throughout the period of exercise
till pairs and subsequent groups are
formed.
Game of Rules
Form two groups with equal
number of members. Call two
people from each group and ask
them to stand on the spots already
decided by the facilitator. Draw two
lines a short distance away from
the two spots and ask all other
members of each group to stand
behind these lines. Now ask the
members on the two spots to stand
facing each other and to then hold
each other's hands and lift them
up to form an arc wide enough to
allow the other participants to run
through it. When the facilitator
announces "start", one participant
from each group must run through
the arc. Each participant in the
group must complete their run,
running Back to their group to
give a pass to the next member,
who in turn must follow the same
procedure. Continue till the last
participant has completed the
run. All participants are required
to follow the following rules in this
game:
1.
2.
3.
4.
They must run the course in
front of their respective groups.
They should not touch anyone
while running.
They must give a pass to the
next group member in line.
All participants must stand
behind their marked starting
line.
Gandhi Thatha Game
The group is asked to form a
standing circle and the facilitator
numbers from 1 to 10. Next, the
should join the circle. It would be
interesting if the facilitator could
share a few thoughts on Mahatma
Gandhi before starting the game.
The rules are that the group must
follow the cue provided by the
facilitator. For example:
"Gandhi tata asks all of us to sit
down."
"Gandhi tata asks all of us to remain
standing."
"Gandhi tata asks all of us to do a
slow jog."
Basket on My Head
t All the participants must stand
in circle. The facilitator should
carry a basket on her head like a
vegetable vendor and approach
one of the participants and loudly
announce her list of vegetables. The
participant must instantly respond
by naming the vegetables. If a
participant fumbles while telling the
names she has to carry the basket
and continue the game. Now, she
must go to another participant and
announce that she is selling fruits
and that participant will have to
instantly come up with the right
answers.
Follow the Leader
Select a leader from among the
participants. She will start the game
1 with an action or sound or both.
Ask the remaining participants
to imitate their leader. When the
facilitator calls out "change",
someone from the group will
assume leadership and continue the
game. Actions commonly include:
dance steps, hunting gestures, or
applying makeup. Stop the game
after a couple of rounds. Encourage
those who come forward when the
change is announced. Continue the
game until a sufficient number of
participants get a chance to play
the leader.
In the River, On the Bank
The participants will stand in two
parallel lines, facing each other.
Explain that all are standing on the
riverbank and one step forward is
the river. Participants will have to
respond instantly to commands of
"River" and "Bank". Start the game
slowly and then increase speed as
you vary the commands. Those who
take a false step in response to the
command will be out of the game.
Number Acting
Start the game by asking
participants to speak aloud the
32 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
numbers will be written in the air by
moving fingers, followed by arms,
heads, and then the entire body,
while both hands are placed on
their waists!
t
Catch the Colour
The participants have to stand in
a circle. The facilitator must loudly
announce different colours one
at a time. For each colour, the
participants must rush towards their
immediate surroundings and get
something matching that colour.
Those who fail to bring anything will
be out of the game.
Chicken and Chimp
Divide the participants into two
groups called Chicken and Chimp.
Members of the two groups should
form two parallel lines, standing
about 5 feet apart. When the
facilitator calls out "Chimp", the
members from that group must
run after the Chicken and catch
them while they try to evade being
caught To make the game more
interesting, the facilitator must
keep suspense alive by starting
with Chi.Chi.Chi...before saying
either Chicken or Chimp! This not
only creates confusion, but also
makes participants more alert as
they eagerly wait their turn either to
catch or to run.
Blind Mice
Ask all the participants to close their
eyes and slowly walk around like
blind mice. They should not bang
into each other. The facilitator must
then ask the group to speed up
their walking and finally ask them to
run. Note: While playing this game,
ensure that there are no obstacles
on which participants can fall or hurt
themselves.
Chain Running
Let all the participants stand
apart and ask one to volunteer
to start the game by running and
touching another member. Now
the other members must avoid
being touched. Those who have
been touched will hold hands and
try to touch others. The chain will
keep getting longer until the last
person has been touched. Once a
complete chain of the participants
is formed, get them to sing a song
while holding hands and moving
around in a circle.
Dance to the Beat
Ask the participants if they would
like to sing a song. Tell them that
you will first start singing these
words very softly: daguchuku
daguchuku daguchuku daguna dam
dam data data data data data data
dara. Then ask the participants to
raise their voice while singing these
words. Then repeat the tune while
holding their hands to be followed
by head shakes. The activity should
end with each member taking
vigorous steps to the tune. All will
join in the dancing and jumping
with enthusiasm.
What-ho, How-much?
The participants will first stand in a
circle and then jog clockwise. While
they are moving, the facilitator in
the middle should repeatedly ask
them "What-ho, How-much?" while
they respond with "As-much-asyou-say" while continuing to jog in
the circle. Suddenly, the facilitator
should say a number, for example
3. Instantly the participants have to
break the circle and form a group
with three members. Anyone who
fails to do so will be out of the
game before it starts again with a
new number. Note: Try variations by
saying "two and half" so that three
members come together with two
standing and one sitting.
Chitty Chitty Bang Bang
The participants stand in a circle
and start saying numbers starting
from 1. When it is the turn of the
fifth participant, instead of saying 5,
she has to say "Chitty Chitty Bang
Bang", accompanied by a clap.
This should be followed by every
fifth participant (i.e., Sth, 10th, 15th,
20th and so on). If anyone just says
"5", or "Chitty Chitty Bang Bang"
without a clap, they have to leave
the game. In that case, the next
person is considered as the Sth
person and is expected to follow
the rules of the game.
10.6
RECAP SESSIONS
AND EVALUATION
ACTIVITIES
Then after each day of training,
conduct an exercise that can give the
facilitator an idea about the extent
of participants’ understanding as
a result of the day’s information.
One suggestion is to have a
brainstorming session at the end
of each day to gather insights
from the participants regarding
learning and to get their opinions
on and reactions to what has been
presented by the facilitator. The
facilitator should try to analyse this
feedback as soon as possible so that
the participants’ likes and dislikes
can be taken into consideration for
future sessions.
Longer-term evaluation activities
enable participants to assess both
the positive and negative effects of
training, focused on modules or
the entire workshop. Each of the
modules can be evaluated through
a process designed to assess the
overall influence the sessions’
messages had on the participants
attitudes, knowledge and practice
levels. A facilitator can ask
participants to reflect on a number
of items including: the relevance of
the topics covered; facilitation style;
facilitators’ use of language; space
to freely express one’s opinions;
methodologies used; scope/level
of participation; handouts and
materials; adequate breaks; food;
and accommodation. Evaluation
is also important in collecting
suggestions for future training
sessions.
In this Tool Kit, each module ends
with a training evaluation and
feedback session using a feedback
form that gathers information on
a number of the identified factors
above.
To ensure that the learning is
lasting, at the start of each training
day, recapture the previous day’s
learning. You can use a quiz
format or any other interesting and
innovative method for the recap.
Design, Planning and Implementation of the Sukshema Project 33
each other. Give each pair 15 minutes to share
names, where the live, information about their
family and any issues concerning their work or
their community that is important to them. Ask
each pair to prepare a very short skit, song or
poem (2 or 3 minutes) on one of these topics.
Then ask the pairs to introduce each other to the
group and give their presentation. The facilitator
should not make any comments on the skits,
songs or poems as this is for entertainment, not
judgement However, if their presentation is too
long, ask the pair to cut it short.
11. GETTING STARTED
Amitabh Bachchan because he is versatile. If the
selected category is flowers, T would like to be a
Jasmine blossom because it smells wonderful ’.
•
Activity 5: Ask a volunteer to stand at the front
of the training room with their back to the
other participants. Stick one of the participant’s
names on the back of the volunteer. Then tell the
volunteer that he/she will need guess the name
of the participant that has been pasted on his/her
back by asking questions to the rest of the group
to guess the name. 'Ihe questions can only be
answered with ‘yes’ or ‘no’ (for example, Ts this
person female?’ or Ts this person working in my
area?’). The volunteer may guess at any time. If
he/she is correct, then the person who answered
the last question will have a new name stuck on
their back, and the activity continues as before.
If they are wrong, they have to continue to ask
more questions. Before starting the activity, agree
on either a time limit or the number of questions
before you change participants.
•
Activity 6: Ask participants to run in a circle.
Play music as they run. Ask them to stop when
the music stops. Announce a number - for
example 3,4,5. Participants should form groups
of 3,4 or 5, accordingly. Each time they meet in
a group, they should share information about
themselves. Encourage participants to form
groups with new participants each time. The
questions they ask of each other could include:
name, designation, organization; favourite
sweets; the person who motivates them the most;
favourite colour and why, etc.
•
Activity 8: Read different statements. Those
who agree with these statements should come
forward, form a group and introduce themselves.
These statements could be: I like to watch
movies; I am always late to office; I have two
children; I am a slow eater; I like formal clothes,
etc.
•
Activity 9: Form two large circles with all
participants - one inside the other. The
participants in the inner circle should face the
participants in the outer circle. Participants in
the inside circle should walk in one direction
and those in the outside circle should walk in the
opposite direction. This way, each participant
gets to face and meet a new person as the circle
continues to move very slowly. When you meet
a new person introduce yourself and share your
area of interest.
11.1 DOORWAY TO SUCCESSFUL TRAINING
•
Welcome Participants
@ Objective
O
To welcome participants to the training and allow the
facilitator to introduce themself and briefly explain the
relevance of the training, including the importance of the
participants' roles.
• Display a welcome sign, a banner, or a PowerPoint
slide that reads '‘Welcome to the Community Level
Interventions for Improving Maternal, Neonatal
and Child Health Training at the front of the
training room as participants enter.
• Welcome the participants and any other guests
who might be present to formally inaugurate the
training workshop.
• Deliver a short lecture that gives information about
the purpose in organizing the workshop.
• Encourage participants to ask questions for
clarification.
Methodology
Duration
Mini-lecture
30 minutes
Training Materials
Welcome signs or banners
Q
Tips for facilitators
Process
The training facilitator makes an introduction and shares
the relevance of the workshop so that the participants
have a clear view of its importance.
•
Introduction of participants
Q
Objective
To allow the facilitator to learn the names of participants
and for the participants to become acquainted with each
other in an enjoyable and relaxed atmosphere that builds
trust and interest in each of the participants.
Methodology
Duration
Individual reflection and
large group sharing
Approximately
45 minutes
Is]/ Training Materials
As required depending on activity chosen
Tips for facilitators
It is important that everyone understands and
respects each other as individual person with unique
characteristics, so the introductions should not stop with
only a name, but should be more intimate.
Activity 2: Each participant should be given a
white postcard-sized piece of paper or card and
a pen. Tell each participant to imagine that the
card is a mirror. Ask them to draw an image of
their face and hair on the card making it as life
like as possible, adding any distinguishing and
individual features, such as moles, beards or eye
glasses. Tell the participants that these cards will
be collected and shuffled and then re-distributed
to the group. The person getting the card then
needs to find that person in the larger group.
Once the two persons have found each other
using the portrait cards give them 10 minutes to
introduce themselves and get to know each other
by asking and telling about their home town,
profession, family, or friends. Have each pan
introduce themselves to the larger group and tell
how they managed to recognize that person from
the drawing.
Activity 3: Participants are asked to introduce
themselves by stating their name along with an
adjective that describes them. The exercise can
be modified by asking participants to choose an
adjective that starts with the same letter as their
name. (For example, I am Simple Sarita). All
subsequent participants are required to repeat
the names and adjectives of previous participants
before stating their name and adjective. (For
example. She is Simple Sarita and I am Macho
Mohan). Continue until all participants have
introduced themselves in this way.
Process
•
• Start off by telling the participants that you would
like to learn everyone’s names, since you are going
to be working together for several days.
• Initiate any one of the following activities:
• Activity 1: The facilitator will ask the
participants to pair up with someone seated
close to them and introduce themselves to
34 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Activity 4: Participants stand, or sit in a circle.
Ask them to think about who they would like to
be and why. They can be asked to choose from
categories of famous people from history, sports,
music, movies or characters who are known in
the local community. Likewise they can be asked
to choose their favourite fruits, colours, cartoon
characters, etc. For example, if the selected
category is movie actors, T would like to be
Design, Planning and Implementation of the Sukshema Project 35
Ground rules for the workshop
Hopes and Fears
To clarify the objectives of the workshop so that everyone
has an understanding of the purpose and scope of the
training.
Methodology
Duration
Large group discussion
30 minutes
O
Objective
Objective
Objective
To agree on a set of rules for the group during the
training workshop.
To allow participants to voice their expectations and fears
about participating in workshop.
Methodology
Duration
Methodology
Reflection and large
group discussion
45 minutes
Large group discussion
£5)
Duration
30 minutes
Training Materials
Training Materials
Objectives listed on chart paper
d
Training Materials
Chart paper and marker pens
Chart paper with two columns labelled 'Hopes' and
'Fears' and marking pens
4Q|
The particular module of the 'Community Level
Interventions for Improving Maternal, Neonatal and Child
Health Training Tool Kit' will determine which objectives
the current workshop should be focusing on. For the
relevant module, review each of the relevant session's
aims that you intend to present in the current workshop
and make a list of those objectives on flip chart paper.
O
d
Tips for facilitators
Tips for facilitators
Process
• Clarify that this workshop will cover material
developed in the ‘Community Level Interventions
for Improving Maternal, Neonatal and Child
Health Training Tool Kit’ There are seven modules
in the Tool Kit, all with a different focus.
• Display the objectives of this training on chart
paper.
• Ask if there are any questions about any of the
objectives.
• Display the objectives in the training
- A core list of ground rules could include:
- Need to be punctual
- Confidentiality
- Good listening practices with only one person talking at
a time
- Avoiding interrupting others
- No mobile phones in training room, or at least kept on
'silent mode'
- Respect for what others are saying...not to judge or
ridicule anyone
- All trying to take part actively in discussion
- Not doing things that hurt or harm others
- Accepting that each of us has a right to change our
minds
- Realising that all questions are worth asking
- Regular attendance at all sessions
Tips for facilitators
The participants may come up with a wide range of
expectations, some’of which may fall outside the scope
of the training program. The facilitator will be responsible
to clarify the scope and limitations of the workshop so
that participants have a realistic view of the workshop's
activities and outcomes.
Process
• Display the chart with two columns labelled
‘Hopes’ and ‘Fears’ at the front of the training
room.
• Ask the group to brainstorm about what issues they
want to put in each column.
• Notes their response on a flip chart.
• When the chart is filled up, go back and discuss
each entry.
• Highlight any of the objectives that were discussed
in the previous session and posted on the training
room wall.
• Clarify any hopes that do not match with the
objectives.
Process
• Tell participants that they should agree on some
ground rules, or ways of preventing any group
tensions or conflicts during the workshop.
• Ask for a volunteer to write down topics while
participants brainstorm ideas that they would like
to include.
• Once all the rules proposed by the group are on
chart paper, review them again together for clarity.
Read out the rules and quiz the group on how each
rule will help prevent tension or conflict during the
workshop.
• Ask for a show of hands that all ground rules are
unanimously agreed upon.
• Ask two participants to volunteer during the
workshop to help remind the group of ground rules
throughout the training workshop.
• Ask them to also: help in maintaining group co
operation and discipline; act as time keepers; and
to liaise with the training team in case of problems.
BI
■
Des>gn, Wanning and imp'-ementst/on of the Sdt thetni Project 37
pm
I
TWO
j
Community Level Interventions
And Child Health: A Training Tool Kit
CORE CONCEPTS OF
MATERNAL NEONATAL
AND CHILD HEALTH
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
Community Level Interventions for
Improving Maternal, Neonatal and
Child Health Training Tool Kit: Core
Concepts of Maternal and Child
Health is the second module of the tool
kit in a series of seven on enhancing
community engagement for improving
CORE CONCEPTS OF
MATERNAL NEONATAL
AND CHILD HEALTH
outreach, shaping demand and
strengthening accountability to improve
maternal, neonatal and child health
outcomes in Karnataka.
ACKNOWLEDGEMENTS
The following institutions and individuals contributed
to the idea, design, writing and editing of this tool kit:
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
Dr. B M Ramesh, UOM
Dr. Krishnamurthy, UOM
Mr. Mohan HL, UOM
Ms. Prathibha Rai, KHPT
Ms. Navya R, KHPT
Dr. Suresh Chitrapu, KHPT
Mr. Balasubramanya KV, KHPT
Dr. Troy Cunnigham, KHPT
Mr. Arin Kar, KHPT
Mr. Ajay Gaikwad, KHPT
Mr. Nagaraj R, KHPT
Mr. Manjunath Dodawad, KHPT
Ms. Lakshmi C, KHPT
Ms. Sharada HR, KHPT
THE EDITORIAL TEAM:
Mr. H.L. Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Ms. Dorothy L. Southern, KHPT Consultant
The photographs are by KV Balasubramanya.
They have been used in the module with consent
from the community.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & Sth Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91-80-40400200
Fax: 91-80-40400300
www.khpt.org
Year of Publication: 2014
Copyright: KHPT
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
•
^^^ukshema
Improved Maternal, Newborn & Child Health
*
I-,
f
ACRONYMS
7
GLOSSARY OF TERMS
8
Getting Started: The Doorway to Successful Training
The Community Level Interventions for Improving Maternal, Neonatal and
Child Health Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 2: Core Concepts of Maternal Neonatal and Child Health
trains the resource persons (RPs) employed by the Sukshema project on
technical information on the maternal neonatal and child health (MNCH)
continuum of care. This continuum includes four stages: Antenatal care - care
during pregnancy; Intra-natal care - care during the delivery and first two hours
after the delivery; Post-natal care (mother and newborn) - care during the first
42 days; and Child care - care of the child up to year 5. The training sessions
details critical issues in the MNCH continuum of care's four stages and lays the
foundation and understanding of related concepts and medical terminologies
among the front line health workers (FLWs), including the Junior Female
Health Assistant (JHA), the Accredited Social Health Activist (ASHA), and the
Anganwadi Worker (AWW).
13
SESSIONS
Session 1/Understanding MNCH
14
Session 2: Antenatal care
18
Session 3: Delivery / intra-natal care
24
Session 4: Post-natal care
30
Session 5: Child care
35
Session 6: Critical issues in MNCH continuum of care
37
Session 7: Post-test and training evaluation and feedback
42
ANNEXURES
Annexure 1: Reading material on MNCH care continuum
44
Annexure 2: Reading material on Antenatal care
45
Annexure 3: Reading material on Delivery/ Intra-natal care
50
Annexure 4: Reading material on Post-natal care
52
Annexure 5: Reading material on Child care
59
Annexure 6: Post-test for Module 1
66
Core Concepts of Maternal Neonatal and Child Health
AIDS
ANC
ARI
ASHA
AWC
AWW
BCC
BEmONC
BP
BPL
CBO
CBR
CDR
CEmONC
CHC
CHW
DH
DOH
EDD
EmONC
FRU
FP
FWC
Hb
HbsAg
HBNC
HBMNC
HIV
ICDS
ICU
IDD
IEC
IFA
IMR
IMNCH
Acquired Immune Deficiency
Syndrome
Ante Natal Care
Acute Respiratory Infection
Accredited Social Health
Activist
Anganwadi Centre
Anganwadi Worker
Behaviour Change
Communication
Basic Emergency Obstetric and
Neonatal Care
Blood Pressure
Below Poverty Line
Community Based Organization
Crude Birth Rate
Crude Death Rate
Comprehensive Emergency
Obstetric and Neonatal Care
Community Health Centre
Community Health Worker
District Hospital
Department of Health
Expected Date of Delivery
Emergency Obstetric and
Newborn Care
First Referral Unit
Family Planning
Family Welfare Centre
Haemoglobin
Hepatitis B Surface Antigen
Home based Newborn Care
Home based Maternal
Newborn Care
Human Immuno-deficiency
Virus
Integrated Child Development
Services
Intensive Care Unit
Iodine Deficiency Disorders
Information, Education,
Communication
Iron and Folic Acid
Infant Mortality Rate
Integrated Management of
Neonatal and Childhood Illness
INC
IPC
J HA
JSY
LBW
MDG
MMR
MNCH
MNT
MO
NGO
NID
NSS
NRHM
OPD
ORS
ORT
PHC
PNC
PPP
PPPCT
PPH
PRI
RCH
RKS
RTI
SBA
SC
STI
TBA
TH
TT
UIP
UNICEF
VHND
VHW
VHSNC
WHO
Intra-natal Care
Inter Personal Communication
Junior Female Health Assistant
Janani Suraksha Yojana
Low Birth Weight
UN Millennium Development
Goals
Maternal Mortality Rate
Maternal, Newborn and Child
Health
Maternal and Newborn Tetanus
Medical Officer
Non-Government Organization
National Immunization Day
National Sample Survey
National Rural Health Mission
Out Patient Department
Oral Rehydration Salt
Oral Rehydration Therapy
Primary Health Centre
Postnatal Care
PowerPoint Presentation
Prevention of Parent to Child
Transmission (HIV)
Post-partum Haemorrhage
Panchayat Raj Institution
Reproductive and Child Health
Rogi Kalyan Samiti
Reproductive Tract Infection
Skilled Birth Attendant
Sub Centre
Sexually Transmitted Infection
Trained / Traditional Birth
Attendant
Taluk Hospital
Tetanus Toxoid
Universal Immunisation
Programme
United Nation's Children's Fund
Village Health and Nutrition Day
Village Health Worker
Village Health and Sanitation
Nutrition Committee
World Health Organization
Core Concepts of Maternal Neonatal and Child Health
7
is diagnosed as anaemia. Anaemia is classified as mild,
moderate or severe based on the concentrations of
haemoglobin in the blood. Mild anaemia corresponds to
a level of haemoglobin concentration of 09 to 10.9 g/dl
for pregnant women moderate anaemia corresponds to a
level of 7.0-9.9 g/dl, while severe anaemia corresponds to
a level less than 7.0 g/dl.
GLOSSARY OF TERMS
Acute respiratory infections (ari)
The respiratory tract is an organ starting from the nose
to the alveoli and organs such as the sinuses, middle
ear cavity and pleura. Infection is the entry of germs
or microorganisms into the human body and multiply,
causing symptoms of illness and acute infection is an
infection that lasts up to 14 days. Ari can be caused by
viruses, bacteria or riketsia, while often a complication
of bacterial infections caused by respiratory viruses,
especially if there is any epidemic or pandemic.
Respiratory infections are responsible for almost 20%
of all under-five deaths worldwide. Any child who has a
cough, is breathing faster than usual with short, quick
breaths or is having difficulty in breathing, (exduding
children that had only a blocked nose) should be
presumed to have ari and taken to health care provider.
Amniotic cavity / sac
Amniotic cavity is the space within the uterus in which
the foetus resides, bound by the amniotic membrane.
The membranes which make up the sac may occasionally
rupture naturally as labour begins, but usually remain
intact until the end of the first stage of labour. The sac
or 'bag of water* as is commonly called us filled with
amniotic fluid in which the developing baby grows.
Amniotic fluid
The fluid within this amniotic cavity / sac is called the
amniotic fluid. This is clear straw-coloured liquid sac
helps the foetus to grow uniformly and develop bones
and muscles. Babies breathe this fluid in and out of their
lungs in the womb helping the lungs to grow as well. It
also keeps the amnion (membrane) from sticking to the
foetus.
It cushions the baby against pressure and knocks, allows
the baby to move around and grow without restriction,
keeps the baby at a constant temperature, and provides
a barrier against infection.
Anaemia
Anaemia is the shortage of red blood cells in the body,
leading to an inability of the blood to carry oxygen
around the body. It is a condition rather than a disease
itself. Anaemia occurs when you have a below-normal
level of haemoglobin or haematocrit. Symptoms include
weakness, lethargy, paleness and breathlessness. It may
be caused by a lack of iron in the diet, blood loss, chronic
illness, a genetic or acquired disease or defect, or it may
be caused by a side effect of medication.
For any pregnant woman the haemoglobin level should
be 11-16 gm hb/dl. If it is lower than this normal level it
8
Antenatal care
Medical care for a pregnant woman and her developing
baby for the duration of the pregnancy
ASHA
An Accredited Social Health Activist (ASHA) is a
community based health functionary in the rural areas.
ASHAs are supposed to create awareness and provide
information to the community on determinants of health
such as nutrition, basic sanitation and hygienic practices,
healthy living and working conditions, information on
existing health services and the need for timely utilization
of health and family welfare services.
Birth asphyxia
It is the medical condition resulting from deprivation of
oxygen to a newborn infant that lasts long enough during
the birth process to cause physical harm, usually to the
brain. Hence the newborn infant fails to start breathing
on its own in the minutes following birth.
Birth weight
It is the first weight of the foetus or newborn obtained
after birth. For live births, birth weight should preferably
be measured within the first hour of life before significant
postnatal weight loss has occurred. At full term, the
average baby will be about 20 inches (51 cm) long and
will weigh approximately 6 to 9 pounds (2700 to 4000
grams). Any baby with a birth weight under 2500 grams
is a low birth weight baby (LBW). LBW babies are usually
premature as well. However, some LBW are full term,
but undernourished and under-grown. LBW babies have
increased risks of lung, heart and metabolic problems.
They often require treatment in a special care nursery or
NICU.
Caesarean section
Delivery of the baby through surgical extraction /an
incision in the abdominal and uterine walls when delivery
through the vagina/ birth canal is deemed unsafe is
called Caesarean section.
Colostrum
A thin white opalescent fluid, the first milk secreted
shortly after delivery and before mature breast milk
is produced. It differs from the milk secreted later
by containing more lactal-bumin and lacto-protein;
colostrum is also rich in antibodies that confer passive
immunity to the newborn and helps in resisting infection.
Congenital anomalies
Something that is unusual or different at birth.
Congenital malformation
A physical defect present in a baby at birth that can
involve different parts of the body including the brain,
heart, lungs, liver, bones, and intestinal tract is called
congenital malformations. Congenital malformation
can be genetic, it can result from exposure of the foetus
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
to a mal-forming agent (such as alcohol), or it can be
of unknown origin. Congenital malformations are now
the leading cause of infant mortality (death) in many
developed nations. Examples include heart defects,
cleft lip and palate, spina bifida, limb defects, and Down
syndrome.
Cord prolapsed
A condition when the umbilical cord falls through the
cervix and possibly even into the vaginal canal, usually
during labour or when water breaks ahead of the baby's
head or other parts of the baby's body. Delivery or
caesarean is usually performed immediately. A prolapsed
cord is a serious emergency and can be very harmful to
the baby. When the cord is compressed or squeezed (for
example, between the baby and the wall of the uterus
or vagina), the baby’s supply of blood and oxygen is cut
off. The lack of oxygen (birth asphyxia) can lead to severe
damage or death if the problem is not taken care of within
minutes.
Diarrhoea
Diarrhoea is a common condition that involves unusually
frequent and liquid bowel movements. There are many
infectious and non-infectious causes of diarrhoea.
Persistent diarrhoea is both uncomfortable and dangerous
to the health because it can indicate an underlying
infection and may mean that the body is not able to
absorb some nutrients due to a problem in the bowels.
Treatment includes drinking plenty of fluids to prevent
dehydration and taking over-the-counter remedies.
Diphtheria
Diphtheria is an acute infectious disease that typically
strikes the upper respiratory tract including the throat. It
is caused by infection with the bacteria Corynebacterium
diphtheriae. Symptoms include sore throat and mild
fever at first. As the disease progresses, a membranous
substance forms in the throat, which makes it difficult to
breathe and swallow.
Foetal distress
Foetal distress is a complication when during labour
bab/s heart beat becomes flat, or drops to a lower level
repeatedly causing stress for the baby. Sometimes during
labour and delivery the foetus may not get enough oxygen
from the placenta and may become "distressed". When
this happens, the foetal heart rate may show patterns
consistent with oxygen deprivation.
Five cleans
A major factor contributing to neonatal and maternal
infections is unhygienic delivery practices. Hence five
cleans that are a must during delivery to ensure hygienic
practices are:
• Clean hands - wash and wear gloves
• Clean delivery surface - take care that it is dry
• Clean cord cut - use sterile blades to cut the cord
• Clean cord ties - use sterile clips or ties and leave 2
finger length of the cord.
• Clean cord stump care - do not apply anything as there
is a danger of infection / tetanus and subsequent death
if proper care is not taken
Gestation
The period of foetal development from conception until
birth is called gestation or pregnancy.
Total gestation period = 40 weeks
• Full term = 37-42 weeks
• Pre-term < 37 weeks
• Post-dates > 42 weeks
Total gestation period is divided into three trimesters • 1st trimester = 0-12 weeks
• 2nd trimester = 12-28 weeks
• 3rd trimester = 28 to 40 weeks
Hepatitis
Inflammation of the liver from any cause is called
Hepatitis. Depending on the type of virus, there are
different types of Hepatitis.
Hydramnios
Hydramnios is an excess of amniotic fluid in the uterus
during pregnancy.
Infant
A young baby, from birth to 12 months of age is called
infant
Infant Mortality Rate
Infant Mortality Rate (IMR) is the number of deaths
under one year of age occurring among live births in a
given geographical area during a given year, per 1000
live births occurring among the population of the given
geographical area during the same year. In other words
it is the number of children dying at less than 1 year of
age, divided by the number of live births that year.
Instrumental delivery
Term used to describe either a forceps or ventouse
(vacuum) delivery
Kangaroo care
It means holding a baby in a skin-to-skin contact with
the mother. The baby is placed on the mother's chest,
dressed in a diaper and sometimes a cap. The baby's
head is turned to the side so that the baby's ear is
against the mother's heart. In this position the baby is
able to find comfort in the mother's heartbeat and feel
the mother's warmth. This procedure is limited to babies
whose condition is not critical and facilitates bonding
between mother and child. Kangaroo care can be done
with any infant who is medically stable. Kangaroo care
has been shown to have several benefits for premature
babies and their mothers. It helps babies breathe and
sleep better, gain weight more quickly, and have more
stable temperatures. Mothers who practice kangaroo
care have better milk supplies and less depression.
Labour
The process of delivering a baby and the placenta,
membranes, and umbilical cord from the uterus to the
vagina to the outside world is called labour.
False labour
Uterine contractions that are irregular, do not increase
in frequency or severity, and do not efface or dilate the
cervix are called false labour.
True labour
The labour pains are true when the contractions in the
uterus cause discomfort or a dull ache in the back and/
or lower abdomen. There is pressure in the pelvis and
Core Concepts of Maternal Neonatal and Child Health
9
then the ache comes in front. Some women may also
feel pain in their sides and thighs. Contractions become
intense and frequent. The contractions come at regular
It may result in a need for caesarean delivery. A caesarean
delivery may be recommended for any of the foetal
positions other than cephalic.
intervals and last about 30-70 seconds.
Four stages of labour
• 1st stage = onset of pain till full dilatation of cervix
(10 cms); 12 hours in primi gravida and half time
subsequently
• 2nd stage = full dilatation of cervix to delivery of
the baby; 2 hours in primi gravida and halftime
subsequently
• 3rd stage = delivery of baby to delivery of placenta; 15
minutes in primi gravida and others
• 4th stage - recovery stage (first one hour after delivery
of placenta)
Live birth
According to WHO the definition of live-birth is 'Live
birth refers to the complete expulsion or extraction
from its mother of a product of conception, irrespective
of the duration of the pregnancy, which, after such
separation, breathes or shows any other evidence of
life - e.g. beating of the heart, respiration, pulsation of
the umbilical cord or definite movement of voluntary
muscles - whether or not the umbilical cord has been cut
or the placenta is attached. Each product of such a birth
is considered to be live birth.
Lochia discharge
The normal uterine discharge of blood, tissue, and mucus
from the vagina after childbirth is called lochia discharge.
Lochia contains blood, tissue from the placenta, and
mucus. It's how the body gets rid of the lining of the
uterus (womb) after birth. The blood may come out in
gushes or flow more evenly like a heavy period. It is also
known as: postpartum bleeding, postpartum vaginal
discharge, bleeding after childbirth. The blood changes
colour and becomes lighter as uterus heals and returns to
its pre-pregnancy size. At first the flow of lochia is heavy
and bright red, and may have clots in it Gradually, it
changes to pink then brownish and, eventually, to yellow
white. Lochia has an odour similar to that of normal
menstrual flow. If there is an offensive or abnormal odour
during lochia, it is important to contact the physician for
evaluation.
Mai presentations
Normally, the presentation of a foetus about to be
born refers to which anatomical part of the foetus is
leading, that is, is closest to the pelvic inlet of the birth
canal. According to the leading part, this is identified
as a cephalic, breech, or shoulder presentation. A mal
presentation is any other presentation than a vertex
presentation (with the top of the head first). If any part of
the baby other than the top of baby's head or the buttock
enters the pelvis first, it causes a complication during a
vaginal delivery.
Cephalic (head-first) presentation
Cephalic presentation is considered normal and occurs
in about 97% of deliveries. There are different types
of cephalic presentation, which depend on the foetal
attitude. Rarely, the foetus' head is extended back, and
the chin, face, or forehead will present first depending on
the degree of extension. This is a more difficult delivery,
because this is not the smallest part of the foetus' head.
Neonatal
Of/or relating to newborn children.
Breech presentation
Breech presentation is considered abnormal and occurs
about 3% of the time. A complete breech presentation
occurs when the buttocks present first, and both the hips
and knees are flexed. A frank breech occurs when the
hips are flexed so the legs are straight and completely
drawn up toward the chest. Other breech positions occur
when either the feet or knees come out first.
Shoulder presentation
The shoulder, arm, or trunk may present first if the foetus
is in a transverse lie. This type of presentation occurs less
than 1 % of the time. Transverse lie is more common with
premature delivery or multiple pregnancies.
Maternal Mortality Rate
The maternal mortality rate (MMR) refers to the number
of deaths from puerperal causes occurring among the
female population of a given geographical area during a
given year, per 100, 000 live births occurring among the
population of the given geographical area during the
same year. In other words it is the number of registered
maternal deaths due to birth- or pregnancy-related
complications per 100,000 registered live births.
Measles
Measles is an acute and highly contagious viral disease
characterized by fever, runny nose, cough, red eyes, and
a spreading skin rash. Measles, also known as rubeola,
is a potentially disastrous disease. It can be complicated
by ear infections, pneumonia, encephalitis (which can
cause convulsions, mental retardation, and even death),
the sudden onset of low blood platelet levels with severe
bleeding (acute thrombocytopenic purpura), or a chronic
brain disease that occurs months to years after an attack
of measles.
Meconium stained liquor
Meconium is a dark green liquid normally passed by the
newborn baby, containing mucus, bile and epithelial
cells. Meconium stained amniotic fluid / 'liquor* is when
the baby opens their bowels inside the uterus, making
the waters look green, yellow or brownish in colour.
Meconium stained liquor is usually associated with a
response from the baby to having a temporarily reduced
oxygen supply at some point in time (usually during
labour) or a slowly reducing level of oxygen over a period
of time.
Multiple pregnancies
Multiple pregnancies are where more than one foetus
develops simultaneously in the womb. The presence
of more than one foetus in the uterus increases the
likelihood of birth defects as well as problems during
labour and delivery.
Multi-para
A woman who has given birth previously at least twice.
Grand Multi para
A woman who has given birth previously five or more
times.
10 Community Level interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Neonatal period
The first 28 days of life.
Early neonatal period
It is the period between 0-7 days.
Late neonatal period
It is the period between 8-28 days.
Obstructed labour
When a foetus cannot progress into birth canal due to
some type of obstruction is called obstructed labour.
Prolonged and/or obstructed labour accounts for about
8% of direct maternal deaths in developing countries. If
a woman with prolonged and/or obstructed labour does
not receive timely and effective management, she may
die from rupture of the uterus or infection. Foetal deaths
are also common if prompt treatment for obstructed
labour is not undertaken.
Pallor
Pallor is a clinical manifestation consisting of an unnatural
paleness of the skin.
Perinatal period
The perinatal period commences at 20/ 22 completed
weeks (140/154 days) of gestation and ends 7 to 28
completed days after birth.
Perineum
The area of the body between the anus and vulva in
females and between anus and scrotum in males is called
perineum.
Pertussis
It is known as whooping cough; an infectious a
communicable, potentially deadly illness disease caused
by the bacteria called by Bordetella pertussis, marked by
catarrh of the respiratory tract and peculiar paroxysms
of cough, ending in a prolonged crowing or whooping
respiration. It is characterized by fits of coughing followed
by a noisy, 'whooping' indrawn breath. Immunization
with DPT (diphtheria-pertussis-tetanus) vaccine provides
protection against the disease.
Placenta
Placenta is a flattened circular organ in the uterus of
pregnant eutherian mammals which permits metabolic
interchange between foetus and mother and nourishes
the foetus through the umbilical cord. It develops during
pregnancy and permits the absorption of oxygen and
nutritive materials into the foetal blood and the release
of carbon dioxide and nitrogenous waste from it, without
the direct mixing of maternal and foetal blood. It is
expelled following birth.
Poliomyelitis
Popularly known as polio, Poliomyelitis is an acute viral
disease usually caused by a poliovirus and marked
clinically by fever, sore throat, headache, vomiting, and
often stiffness of the neck and back; these may be the
only symptoms of the minor illness. In the major illness,
which may or may not be preceded by the minor illness,
there is central nervous system involvement, stiff neck,
pleocytosis in spinal fluid, and perhaps paralysis; there
may be subsequent atrophy of muscle groups, ending in
contraction and permanent deformity.
Post-neonatal period
It refers to the period from the fourth week after birth to
the end of the first year.
Post-partum
Traditionally the postpartum period ends 6 weeks
after birth. However, WHO has designated the first 28
completed days after birth of the infant as the neonatal
period.
Post-partum haemorrhage (PPH)
This is excessive bleeding following delivery. It is defined
as blood loss greater than 500 ml or of the amount
that adversely affects the maternal physiology. It is
categorized as immediate (within the first 24 hours after
birth) or delayed (after 24 hours postpartum).
Pre-eclampsia and eclampsia
A condition in pregnancy characterized by abrupt
hypertension (a sharp rise in BP), albuminuria (leakage of
large amounts of the protein albumin into the urine) and
oedema (swelling) of the hands, feet, and face is called
preeclampsia. It is the most common complication of
pregnancy. It affects about five percent of pregnancies. It
occurs in the third trimester (the last third) of pregnancy.
In preeclampsia, the woman has dangerously high BP,
swelling, and protein in the urine. If allowed to progress,
this syndrome leads to eclampsia. The preeclampsia
eclampsia continuum (also called pregnancy-induced
hypertension or PIH). In this type of hypertension, high
BP is first noted sometime after week 20 of pregnancy
and is accompanied by protein in the urine and swelling.
Pregnancy outcomes (dead or alive)
• Live-birth
• Neonate = newborn
• Abortion < 20 weeks
• Stillbirth > 20 weeks
Pre-lacteal feed
Preceding the establishment of milk flow in the newly
delivered mother; the newborn baby used to be fed
with carbohydrate-electrolyte solutions to reduce initial
weight loss until breast feeding is fully established. This
feed is called pre-lacteal feed.
Pregnancy induced hyper tension (PIH)
There is a chance of hyper tension in pregnancy which is
called pregnancy induced hyper tension (PIH) pregnancy
induced hypertension (PIH) is a condition of high BP
during pregnancy. It can lead to a serious condition
called preeclampsia (also sometimes referred to as
toxemia). The normal BP is 120 (systolic)/ 80 diastolic
Mm/hg. If it is more, it is called hyper tension.
Preterm
An infant bom between the 20th to the 38th week
of gestation (134 to 266 days). Normal gestation is
approximately forty weeks.
Primi gravida
A woman who is pregnant for the first time. If she is over
35 she may be referred to with the term 'elderly primi gravida.'
Core Concepts of Maternal Neonatal and Child Health 11
Multi gravida
A woman who has been pregnant two or more times.
Prolonged labour (Refer to obstructed labour)
Labour more than 24 hours duration is called prolonged
labour. This may be due to a prolonged latent phase i.e.
more than 20 hours in a primi gravida or more than 14
hours in a multipara, or due to a 'protraction disorder* in
which there is protracted cervical dilatation in the active
phase of labor and protracted descent of the foetus.
Sepsis
Sepsis is an infection. It signifies the presence of bacteria
(bacteremia) or other infectious organisms or their
toxins in the blood (septicemia) or in other tissue of the
body. Sepsis may be associated with clinical symptoms
of systemic (body wide) illness, such as fever, chills,
malaise (generally feeling "rotten"), low BP, and mental
status changes. Sepsis can be a serious situation, a life
threatening disease calling for urgent and comprehensive
care.
Stillborn
If the baby dies before delivery it is called as stillbirth.
It usually refers to a pregnancy loss after 20 weeks of
gestation or loss of a baby weighing 350 or more grams.
Tetanus
An often fatal infectious disease caused by the bacteria
Clostridium tetani. It usually enters the body through a
puncture, cut, or open wound. Tetanus is characterized
by profoundly painful spasms of muscles, including
"locking" of the jaw so that the mouth cannot open
(lockjaw). C. tetani releases a toxin that affects the motor
nerves, (the nerves which stimulate the muscles). DPT
immunization provides protection to a child against
tetanus.
Uterus
The uterus (womb) is a hollow, pear-shaped organ
located in a woman's lower abdomen between the
bladder and the rectum. The narrow, lower portion of the
’ uterus is the cervix; the broader, upper part is the corpus.
The corpus is made up of two layers of tissue.
Vaccination
Injection of a killed microbe in order to stimulate
the immune system against the microbe, thereby
preventing disease is called vaccination. Vaccinations, or
immunizations, work by stimulating the immune system,
the natural disease-fighting system of the body. The
healthy immune system is able to recognize invading
bacteria and viruses and produce substances (antibodies)
to destroy or disable them. Immunizations prepare the
immune system to ward off a disease. To immunize
against viral diseases, the virus used in the vaccine has
been weakened or killed. To only immunize against
bacterial diseases, it is generally possible to use a small
portion of the dead bacteria to stimulate the formation
of antibodies against the whole bacteria. In addition to
the initial immunization process, it has been found that
the effectiveness of immunizations can be improved by
periodic repeat injections or 'boosters'.
• Infant = birth to 1 year
• Neonatal period = birth to 28 days
• Post-neonatal period = 29 days -1 year
• Early neonatal period - 0-7 days
• Late neonatal period = 8-28 days
• Peri-natal period = 28 weeks to 7 days
Thalassaemia
Thalassaemia is an inherited disorder of red blood cells
resulting from the absence or deficiency in one or more
of the constituents of hemoglobin. The protein-iron
complex in RBCs facilitates oxygen transport in our body.
Depending on the defect, thalassaemia symptoms vary
in intensity from unnoticeable to life-threatening, and
include anaemia and instability of RBCs, treatable by
regular blood transfusions. Thalassaemia is only curable
by bone marrow transplants from compatible donors.
Tuberculosis
Tuberculosis (TB) is a chronic and highly contagious
infectious disease caused by the closely related species
of the bacteria. TB is more common in people with
immune system problems, such as AIDS, than in the
general population.
Umbilical cord
Umbilical cord connects the developing embryo or fetus
with the placenta. Umbilical arteries and vein run through
the cord. The substance of the umbilical cord is known as
Wharton's jelly and is a rich source of stem cells. At birth
the umbilical cord measures about 20 inches (50 cm) in
length. The cord is clamped and cut after birth and its
residual tip forms the umbilicus (bellybutton).
12 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
GETTING STARTED
The Doorway to Successful Training in Part 11 of
Module 1 should always be used to start a training
workshop: initially if covering all modules at one time,
or as a refresher if modules are scheduled over a period
of time. The Doorway to Successful Training contains
a detailed plan of sessions that sets the stage forthe
workshop activities and logistics, covering welcome,
introductions, objectives, hopes and fears, and
ground rules.
SESSION 1:
UNDERSTANDING
MNCH CONTINUUM
OF CARE
Process
Objective
• To help participants understand the Maternal, Neo-natal
and Child Health (MNCH) continuum of care to reduce
child mortality and prevent maternal deaths
• Magnitude of MNCH related morbidity and mortality
• Major causes of maternal deaths and deaths in neonates
and children under five
• Gaps in MNCH service delivery and utilization in the
Sukshema project's operational areas
• MNCH continuum of care
• MNCH service provision structure
• Basic facts and definitions related to MNCH
* Methodology
PowerPoint Presentation (PPP)
and discussion
• Emphasize the key fact: Most deaths of infants occur
during the first 24 hours after birth. A large percentage
of these infant deaths are due to conditions that
could be prevented or treated with access to simple,
affordable interventions.
• Explain that this knowledge is used as a basis for
planning MNCH services. Home visits are planned
to identify any problems and to bring needed
interventions to mothers, newborns and children to
improve their health and chances of survival.
Duration
2.5 hours
Training Materials
Laptop, LCD projector, screen and pointer, PPP: Continuum
of care, Background material 1: MNCH Care Continuum
Tips for facilitators
This is a critical session to make the field workers
understand the rationale and need for a focused
intervention package in ensuring care throughout the
continuum cycle. This session will set the tone of the
training and requires a technical co-faciTrtator who is a
senior medical doctor with experience of handling MNCH
issues. Read the background material carefully, especially
with reference to the statistics, and understand all issues
presented.
1.3 MAJOR CAUSES OF MATERNAL DEATHS
AND DEATHS IN NEONATES AND
CHILDREN UNDER FIVE
1.1 INTRODUCTION
• Ask participants, ‘What is health?’
• Encourage them to come up with ideas. Ask
probing questions until you get some responses.
• Note their responses on a flip chart
• Then write the complete definition of health as
suggested by the World Health Organization
(WHO): “Health is a state of complete physical,
mental, and social well-being, and not merely the
absence of disease or infirmity”.
• Explain that health is holistic, not just the absence
of illness and explain the meaning of each aspect
of health - physical, mental and social.
• Ask them if they know the meaning of the
acronym MNCH. If not, introduce the topic of
Maternal, Neo-natal and Child Health. Tell them
MNCH covers care of pregnant women, care
during the delivery, care of the newborn/ child and
the newly delivered mother.
• Tell them that the following topics will be covered
in the session:
- Magnitude of MNCH related morbidity and
mortality
- Major causes of maternal deaths and deaths in
neonates and children under five
- Gaps in MNCH service delivery and utilization
in the Sukshema project’s operational areas
- MNCH care continuum
- MNCH service provision structure
- Basic facts and definitions related to MNCH
1.2 MAGNITUDE OF MNCH RELATED
MORBIDITY AND MORTALITY
• Use PPP to provide the worldwide statistics on
maternal and infant morbidity and mortality.
Explain the scenario with reference to India and
then more specifically with northern Karnataka.
• Explain the key terminology used in the session MMR, IMR, live births, etc. and relate it with the
Millennium Development Goals (MDGs). Refer to
the list of acronyms in Module 2.
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
A. CAUSES FOR MATERNAL DEATHS
• Ask participants to brainstorm major causes of
maternal deaths.
• Note their responses on a flip chart.
• Ask them to divide these causes into direct/immediate
causes and indirect causes/factors that might influence
the direct/immediate causes. Tell them that indirect
causes could include social, cultural or economic
factors.
• Stress that while both direct and indirect cause are
important, this session will focus on direct causes as
the overall objective is to work with the ASHAs and
JHAs so they can take appropriate steps to address the
direct causes of maternal deaths.
• Explain that while all the causes they have shared lead
to maternal deaths, a number of studies and surveys
have substantiated five major medical causes/factors
that lead to most maternal deaths.
• Use PPP to show the primary five causes as:
- Haemorrhage (37%)
- Infection (Sepsis) (11%)
- High blood pressure (BP) or hyper tension
pregnancy-induced hypertension (PIH) or eclampsia
(5%)
- Obstructive labour or the failure to progress the
delivery due to problems such as a mismatch
between foetal size/presenting part of the foetus, and
the mother’s pelvis, position of foetal head, malpresentations (5%)
- Abortion (8%)
• Share the percentages of deaths due to each cause and
note these statistics provide evidence-base decision
making for policy makers when planning allocations
of resources, both human and financial, to tackle this
problem.
B. CAUSES OF NEONATAL AND CHILD DEATHS:
• Ask participants to brainstorm the direct causes of
neonatal and child deaths.
• Note their responses on a flip chart.
• If these causes are among those which are included
in the top five causes, congratulate them for their
understanding.
• Otherwise tell them that all the causes they fisted do
lead to neonatal/ child deaths, but are not among the
top causes.
• Use PPP to show the top causes are as follows:
Causes of the neonatal deaths
- Sepsis/pneumonia (30.4%)
- Birth asphyxia (19.5%)
- Prematurity (16.8%)
Causes of the child deaths
- Neonatal conditions (33%)
- Pneumonia (22%)
- Diarrhoea (14%)
» Explain the new words and concepts such as Neonatal
sepsis, birth asphyxia, premature births. Explain
the signs and symptoms of sepsis and birth asphyxia
and inform them that if a baby is premature the vital
organs may not be fully developed and hence the
baby can have breathing problems, infections and
physiological defects. It can have a very low birth
weight (less than 2.5 kg or 2500 grams). These babies
are called low birth weight (LBW).
• Explain the importance of institutional delivery to
prevent problems such as oxygen deprivation and
infections due to lack of hygiene.
• Tell them that Bacillus Calmette-Guerin (BCG)
vaccine can be given as per schedule if institutional
delivery takes place and breast feeding of colostrum
can be initiated.
• Ask when most neonatal and child deaths occur?
• Note their responses on a flip chart.
• Emphasize the key fact: Most deaths occur during
childbirth and within 24 hours of birth due to
delivery at home or during delayed transportation as
immediate access to medical care is not available.
1.4 GAPS IN MNCH SERVICE DELIVERY AND
UTILIZATION IN THE SUKSHEMA
PROJECT'S OPERATIONAL AREAS IN
NORTHERN KARNATAKA
• Ask participants if they have seen or have heard about
any cases of maternal, neonatal or child deaths?
• Give two participants the chance to share details
of their experiences. Ask the group to explore the
situations and the outcomes by asking questions.
• Ask them why these deaths are still occurring when
they can be prevented?
• Note their responses on a flip chart.
• Group these responses under the following headings:
- Gaps in the community
- Gaps in the service providers
• Use PPP to show the reasons for poor MNCH
outcomes and discuss the gaps in the service delivery
Core Concepts of Maternal Neonatal and Child Health 15
and utilization in northern Karnataka.
• Explain that the gaps are evident from:
- The demand side (Le. gaps seen in the community
in awareness about the MNCH care, danger signs,
benefits of institutional delivery and availability
of services, practices in accessing institutional
care, accountabfiity and community monitoring of
services to bring about improvement).
- The supply side (Le. availability, accessibility and
quality of services).
- The interaction between health care providers
(FLWs such as ASHA and JHA) and the community.
• Explain that these gaps impact in community losing
trust in the health care sector, not accessing health
services and thus increasing the maternal and infant
mortality rates.
• Tell the participants that the Sukshema project aims
to address these gaps by supporting the FLWs and
VHSNCs, to rebuild the trust of pregnant women and
their family members in the MNCH services and to
access them.
is essential for mothers and children from pre
pregnancy to delivery, the immediate postnatal
period, and childhood.
• Use PPP to explain how the access to effective
interventions across the MNCH continuum of care
can prevent maternal, neo-natal and child deaths.
• Explain that poor health, malnutrition and
inadequate care of the pregnant woman results into
premature deaths, sick newborns and low birth
weight newborns. It also results in more infections
and developmental problems in children.
• Highlight that as each component in the MNCH is
linked with the other, they demand an integrated
approach.
• Explain the MNCH continuum of care as
- Antenatal care - care during pregnancy
- Intra-natal care - care during the delivery and first
two hours after the delivery
- Postnatal care (Mother and newborn) - care during
the first 42 days
- Child care - care of the child up to age 5.
1.5 MNCH CARE CONTINUUM
• Introduce the important concept of the MNCH
continuum of care.
• Ask them what they think the term MNCH
continuum of care means.
• Note their responses on a flip chart.
• Use PPP to explain that the MNCH continuum of
care starts from the inset of adolescence to pregnancy
to delivery to post natal care to children under five
and goes a full circle again.
• Brainstorm the different stages of womans life.
• Note their responses on a flip chart.
• Discuss the different issues that women/ girls from
rural areas face during each of these life stages and the
dynamics behind these.
• Give examples from rural areas where girls do not get
proper nutrition in childhood and adolescence and
are forced into marriage at a young age. Elaborate
how these conditions affect their reproductive health
including closely spaced pregnancies, poor access to
information about family planning and pressure to
adhere to traditional practices.
• Emphasize that if a woman can receive MNCH
services during each of her life stages, many
reproductive disorders/health issues could be averted.
• Explain that MNCH services appropriate to each stage
of a womens life cycle, such as nutrition, pregnancy
guidance and care, delivery and post-partum care,
immunization and proper family planning advice,
could result into fewer complications and prevent
most maternal, neo-natal and child deaths.
• Stress that the integrated MNCH continuum of
care approach, instead of the piece-meal approach,
1.6 MNCH SERVICE PROVISION STRUCTURE
• Use PPP to explain the MNCH service provision
structure from bottom level outreach services, which
are available at the basic unit of 1,000 people by the
ASHAs and AWWs, and for 3000 to 5000 people in
SCs where JHAs and male health workers provide
health care.
• Explain the other levels including: PHCs for 25,000
to 30,000 people where Medical Officers, Nurses and
paramedical staff are on duty and normal delivery
and newborn care, and referral services are provided;
Community Health Centre (CHC) for 80,000 to
1,20,000 rural people; the Taluka Hospitals (TH) for
2,50,000 to 3,00,000 people; and District Hospitals
for more than 20,00,000 people where specialists and
emergency care and caesarean section services are
available.
• Explain how the referral services/linkages ensure a
MNCH continuum of care as the woman is able to
get the complete package through any facility that is
appropriate.
16 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
MNCH SERVICE PROVISION
State Health
Department
i
'Z
District Hospital
Avg of 2,000,000 population
'
Taluka Hospital
2,50/500 to 3,00,000
I
Community Health Centre (CHC)
80,000 to 1,20,000 rural population
£
8,
*
Primary Health Centre
...
25,000 - 30,000 population
Medical officer. Nurse, Paramedic staff.....
Sub Centre
E
■
3,000 - 5,000 population
**---------
Auxiliary nurse midwife, Male health worker
Basic units of 1000 population
1.7 BASIC FACTS AND DEFINITIONS
RELATED TO MNCH
• Tell them that it is important to understand the
anatomical and medical terms related to pregnancy
and child birth.
• Ask participants to explain the anatomy of uterus and
the broad functions of the system.
• Use PPP to add/correct/explain and consolidate
the learning to fully explain the anatomy of the
reproductive organs of a women including:
Jfl
- Pregnancy (Gestation)
&!
- Total gestation period
W
- Full term, pre-term and post-dates
'
- Three trimesters
£
- Labour and its four stages
- Pregnancy outcomes and
- Definitions of some terminologies
Fallopian tube
Endometrium.
Myometrium
Cervix ■
• Consohdate the information by highlighting that the
MNCH continuum of care includes the following
services:
- Antenatal care - care during pregnancy
- Intra-natal care - care during the delivery and first
two hours after the delivery
- Postnatal care (Mother and newborn) - care during
the first 42 days
- Child care - care of the child up to age 5
-Hf •<
Vagina—
;•
Core Concepts of Maternal Neonatal and Child Health 17
bleeding unexpectedly. Her husband Srinivas had
gone to visit a temple and would return only after
3 days. Although she was worried, she kept quiet
and planned to go to the hospital when her husband
returned. When her husband came back, he took
her to the hospital. But it was too late, the baby had
already died.
SESSION 2:
ANTENATAL CARE
(ANC)
©
it Process
Objective
• To understand ANC at all stages
• Importance of ANC
• Essential components of ANC
• High risk pregnancy
• Danger signs in pregnancy
• Birth preparedness for a safe delivery
• Key messages
• ASHA's role in ANC
e
e
2.1 IMPORTANCE OF ANC
• Divide the participants into five groups. Give one
of the case studies to each of the groups.
Methodology
Duration
Case study, small group
discussions and presentations in
plenary, PPP and discussion
2.5 hours
Case 1: Savitiia
- Savitha is seven months pregnant and has never
visited a hospital before. She. had come to the
hospital complaining ofa severe headache for three
days and blurred vision. When the nurse at the
PHC checked her BP it was very high. She advised
Savita's husband to take her to the District Hospital
immediately.
Training Materials
Laptop, LCD projector, screen and pointer, photocopies
of Tool 1: Case studies for ANC; PPP: ANC, Background
Material 2: ANC
Tips for facilitators
This is an important session that provides a holistic
understanding of the ANC stage, the care required at this
stage, possible risks and dangers and signals that indicate
urgent referrals to doctors. A senior medical doctor that
has experience of handling MNCH issues should act as a
technical co-facilitator. While consolidating the discussion
on key issues ensure that all the points given in the
background material are included in the discussion.
Case 2: Unia
Uma and her husband both work as agricultural
labourers. Uma had not been having sufficient rest
ar food at regular intervalsfor the last two months
because of the heavy work load. She had visited the
SC when she was in her Sth month ofpregnancy and
was given a TT injection and iron tablets. Uma did
not take half of the iron tablets as her aunt warned
her that ifshe did, the baby would grow too bigfor
her to have a normal delivery and it would result in
a caesarean operation.
Case 3: Radha
24-year-old Radha was 9 months pregnant with his
first child. She started having labour pains around
midnight. After two hours her water bag broke and
the water was clear. Suresh, Radha's father was
not able to arrange fora 108 vehicle (Government
I ambulance) or a private vehicle to go to hospital
far delivery. As the labour pains started getting
, strong, they called in the ASHA at 3:00 a^n. Radha’s
' pressure started dropping and the ASHA had to fetch
’ a JHrl from home. With great difficulty they saved
the lives of the mother and child.
Case 4: Vindhya
s Vindhya was 6 months pregnant. She started
18 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
PREPARATION FOR DELIVERY
i
Case 5: Rani
Rani was a mother of three chiidren and had two
abortions in the past. She contributed to the family
income by rolling papads. Her husband is a daily
wage labourer. She ate only what was left after
feeding her husband and children, which was not
very much food. When she got pregnant again, she
had no money to have any additional food or get any
other help. She was very weak, but was still smiling
when she h uj admitted at the hospital, but died
during delivery.
• Ask group members to read their case study in the
group, discuss and answer the questions below:
- What do you think had gone wrong or right in
this case study?
- Why do you think this happened?
- How do you think this could have been averted?
- Is there anything more that should have been
done?
• Allow 15 minutes for discussion. Aska
representative from each group to take 5 minutes to
read out their case study and share their responses
to the discussion questions.
• Ask other groups to share any other key
information about the case study.
• Probe further and ask all participants these
additional questions:
- Were there any danger signals?
- Were they ignored?
- What could have been the appropriate action in
each case?
• Continue with the next 4 case studies in the same
manner.
• Consolidate the presentations and tell the groups
that ANC stage requires careful care and adherence
to good practices. If ignored, the life of the mother
and child could be in danger.
• Explain that ANC is the particular form of medical
care given to a pregnant woman and her baby
starting from the time of conception up to the
delivery of the baby.
• Tell them that every woman in her ANC stage
needs to remember to:
- Register for ANC services, preferably in the first
trimester.
Registration of name
Urine
test
Blood test
Consume nutritious.
food at least four or
La day
§
Get
enough
rest
Avoid strenuous
(
work
23
J
i
Consume Iron tablets
Know about Schemes
Core Concepts of Maternal Neonatal and Child Health 19
- Keep the ASHA informed about problems
encountered at an early stage
- Take support from neighbours / VHSNC at an early
stage
- Do birth planning and preparation in advance,
including arrangement of money and vehicle to get
to the hospital if necessary.
- Eat nutritious food, get adequate rest, receive
required immunizations at the right time, and take
any medicine as prescribed by doctor.
- Clarify all doubts/preconceived notions about
pregnancy and actual delivery.
- Ensure the ASHA registers them, visits them
regularly and advises the family on issues such
as government schemes, family planning, birth
planning, nutrition, and ANC services
- Recognize danger signs which require immediate
and appropriate action such as:
~ Headache and blurred vision
~ Bleeding
~ Breakage of water bag
~ Convulsion / fits
~ Loss of foetal movement
• Use PPP to explain that the ANC prepares the
pregnant women for successful labour and delivery
process by helping the mother maintain good
health during pregnancy, informing the family
members about pregnancy, labour and child care.
More importantly, it provides a means of detecting
problems with the pregnancy at an early stage when
they are easily treatable and can avert maternal
complications at delivery.
2.2 ESSENTIAL COMPONENTS OF ANC
• Use PPP to continue the presentation on essential
components of ANC
• Explain the necessity of:
- Early registration (after confirmation of pregnancy)
- ANC visits - Minimum 4 (including registration)
• Ask them what could be the advantages of early
registration.
• Note their response on a flip chart.
• Add any missing information and modify/correct
their responses if required.
• Consolidate the benefits of early registration.
• Ask them what could be the importance of ANC visits
byASHA/JHA.
• Note their response on a flip chart.
• Add any missing information and modify/correct
their responses if required.
• Explain that ANC visits should be a minimum of four
(including registration) or once a month in the case of
high risk pregnancies.
• Tell them that ideally these visits should be during the
following period:
- First visit: 8-12 weeks
- Second visit: 24-26 week,
- Third visit: 32 weeks
- Fourth visit: 36-38 weeks
• Explain the rationale behind the schedule of the ANC
visits and regular and specific services given by the
ASHA during the ANC visits.
• Consolidate the benefits of early registration and
follow-through on all visits.
• Focus on preventive measures highlighted by health
education, advice, and counselling on:
- Nutrition - iron and folic add tablets for 3 months
- Vaccination - two doses of TT vaccine
- Birth planning
- Safe abortion
- Family planning
- Institutional dehvery
- Information about government schemes such as JSY,
Madilu Kit, Prasooti Araike.
• Discuss:
- Anaemia
- Pregnancy induced Hyper tension (PIH)
- Need for blood grouping1
• Ensure that participants know where ANC services are
usually provided. Give specific locations if necessary.
- Community level: ASHA, AWW, VHSNC and SCs.
- Facility level:
~ Level 1 - SC and non-24*7 PHC
~ Level 2 - 24*7 PHC2 and non FRU CHC
~ Level 3 - FRU CHC, TH, DH
•
•
•
•
to recognize the danger signals during the antenatal
period.
When danger signs are recognized it is crucial to
immediately refer the case to the nearest ANC service
facility.
Emphasize that this is the responsibility of the RPs to
be aware of these signs and to support the ASHAs and
JHAs in their work to do the needful when necessary.
Use PPP to list the important danger signals that
require immediate hospitalization.
Explain there are other signals that should be referred
to ANC service facilities, but which are not emergencies
that must be hospitalized immediately. These are:
- Severe anaemia - shows iron deficiency
- Night blindness - shows vitamin A deficiency
- Fever - a sign of infection
- White discharge - a sign of infection
- Multiple pregnancies - requires special attention
during dehvery
- Mal-presentations - requires special attention during
delivery
- Pain/burning when urinating - a sign of urinary infection
DANGER SIGNS IN THE PREGNANT WOMAN
1
ft Repeated
burning
m the vagina
2.3 HIGH RISK PREGNANCY
• Ask the participants what is meant by the term high
risk pregnancy.
• Note their response on a flip chart.
• Define high risk pregnancy as one in which some
conditions puts the mother or the developing foetus,
or both at a higher-than-normal risk of developing
complications during or after the pregnancy and
delivery.
• Explain that a pregnancy can be considered a high-risk
pregnancy for a variety of reasons and complications
can be divided into maternal and foetal.
• Highlight that high risk cases should be regularly
monitored by the ASHA by planning monthly visits,
encouraging regular check-ups where ANC services
are available, watching for danger signals, and opting
for institutional dehvery.
2.4 DANGER SIGNS IN PREGNANCY
• Explain that one of the important steps in reducing the
maternal and infant morbidity and mortality is
1 The blood groups are, A, AB, B, O and RH negative and positive
2 Services are available at the PHC on all seven days of the week
and on all 24 hours of each day
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Bleeding from
robkni
1
Visit the health
center
\
inunediatelyifany
of die danger signs
are seen
-
■■■MW
Core Concepts of Maternal Neonatal and Child Health 21
2.5 BIRTH PREPAREDNESS FOR A SAFE
DELIVERY
• Ask participants how women should begin to prepare
for a safe delivery.
• Note their response on a flip chart.
• Use PPP to discuss birth preparedness.
• Explain that identifying the estimated delivery date
(EDD) is important and includes both medical and
non-medical aspects.
• The non-medical aspects include:
- Arranging for the finances for the delivery process.
- Identifying an accompanying person either among
family or friends who can stay during delivery.
- Knowing the contact numbers of ambulance / 108
van or any other available vehicle.
- Knowing the contact numbers of the ASHA and
JHA.
• The medical aspects include:
- Checking for availability of correct blood type from
a nearby blood bank, if it would be required.
- Checking for availability of doctors/specialists
and referral to FRU if there was any complications
during delivery.
2.6 KEY MESSAGES
PREPARATIONS FOR HOSPITAL DELIVERY
• Ask participants to sum up their learning to ensure
that they remember all the information presented in
Session 2.
- Consolidate the key messages as:
- Pregnant women need to register early for ANC
services, preferably within the first trimester.
- Pregnant women must have regular ANC check-ups
- minimum four at regular intervals.
- Pregnant women should eat a nutritious diet
throughout their pregnancy, with a focus on ironrich and high protein foods.
- Birth planning should be done in advance to avoid
last minute emergencies, including arranging for
money, ambulance, blood transfusion, and specialist
care.
- Watch-out for danger signals if the pregnancy is
high risk
- Pregnant women should be in regular contact with
the ASHA who can give her appropriate advice.
______
I
■
\
|
I
<
Sak-ings rot delivery
■ I . . . (exfwnsesl
............................................... ■
Carry mothers card and
other documents while
visiting the hospital
J uflni
Be ready will}
vehicle
:
■
■■
*—'"[j""'
Take somebody along
with you to die hospital
i i
II
One person need^
i to look after the|
‘ house when f ’
{you are| in |
Being prepared well lor »
delivery is important for "
0
sale delivery
S
I
the hospital. 1
'
Core Concepts of Maternal Neonatal and Child Health 23
i
r
L/J
SESSIONS:
DELIVERY/
INTRA-NATAL CARE
the District Hospital. When Shalini reached there
the doctor said that she required blood immediately.
But Shalini did not know her blood group. It took
around an hour to check her blood group. Her blood
group was B negative, but unfortunately there was
no stock ofB negative blood at the hospital Shalini
died before thefamily could find another source of
her blood type.
/I
Process
Objective
• To help participants understand the importance of an
institutional delivery
• Know how an institutional delivery can save the lives of
mothers and babies
• Know the stages of delivery
• Know the danger signals during delivery
• Know the '5' cleans
Methodology
Duration
Case study, small group
discussions and presentations in
plenary, PPP, film and discussion
3 hours
3.1 IMPORTANCE OF AN INSTITUTIONAL
DELIVERY
• Divide the participants into five groups. Give one
of the case studies to each of the groups.
iqj Training Materials
Laptop, LCD projector, screen and pointer, photocopies of !
Tool 2: Case studies for Intra-natal care, PPP: Intra-natal care, :
Film 1: Stages of delivering a baby (There are several videos ■
available on the internet).
Case 1: Smita
When Smita started labour pains at night, her
grandmother conducted the delivery at home. They
were all happy as both the mother and newborn
were in good condition. After 1 hour, however, Smita
started bleeding heavily. But her grandmother was
not worried as she felt that such amount of bleeding
is normal after delivery. At midnight, Smita became
unconscious. Somebodyfrom the community called
108 for ambulance. ThePHC was 10 bn away
from Smitas house. Unfortunately Smita died in the
ambulance.
Tips for facilitators
As this is a technical session, a senior medical doctor
that has experience of handling MNCH issues should act
as a technical co-facilitator. This session emphasizes the
importance of institutional delivery to ensure that the RPs
understand their responsibility to motivate the ASHAs to
convince the pregnant women and their family members to
access institutions for their deliveries.
:
;
;
:
;
Case 2: Lalitha
It was Lalitha's second pregnancy and her parents
wanted her to deliver at home, and since there
were no complications it would be OK. They had
asked a traditional birth attendant to attend to her.
Lalitha started having her labour pains at 8 p.m.
The contractions were good, but the baby’s head was
not moving down. When they realised that there
was a problem, they calledfor the local ASHA. The
ASHA told them to take Lalitha to the hospital, but
the family members did not take her immediately.
Instead they wailed until morning. Later that next
morning, Lalitha delivered a dead baby.
Case 3: Shalini
Shalini delivered a female baby at night at her home.
She had never gone to a JHA or any other health
care provider during her pregnancy. The JHA who
conducted her delivery saw that Shalini was bleeding
heavily and called 108 for the ambulance to send her
to the nearby PHC. The medical officer at the PHC
looked at Shalini in the ambulance and sent her to
24 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Cased: Geeta
Geeta delivered a male baby at the PHC and the
Medical Officer advised her to stay in the PHCfor
two days (48 hours). Her husband Gopal took her
home two hours after the delivery saying that she was
OK and didn’t need to slay there. The next morning
Geeta's family members gave honey and water to the
baby and branded if on the chest and abdomen. In
the evening the baby developed a high fever and had
to be taken to a nearby private hospital. The baby
was admittedfor three days. The family had to spend
about 5 000 rupees for the treatment.
Case 5: Vandana
Vandana started having labour pains early m the
morning. The pains gradually increased. She went
to the SC in the afternoon. The JHA said that the
contractions were good, but she said that she was
not able to hear thefoetal heartbeat. She advised
them to consult the doctor at the PHC. The Medical
Officer examined Vandana and found that the foetus
was lying transversely and she needed a caesarean
section. He referred Vandana to the Taluka hospital,
but the specialist was not on duty, so Vandana was
referred to the District Hospital, which was very far
away. Despite being very late in the evening they set.
out. The baby was at very high risk and died.
• Ask group members to read the case study in the
group, discuss and answer the questions below:
- What do you think had gone wrong or right in this
case?
- Why do you think this happened?
- How do you think this could have been averted?
- Is there anything more that should have been done?
• Allow 15 minutes for discussion. Ask a representative
from each group to take 5 minutes to read out their
case study and share their responses to the discussion
questions.
• Ask other groups to share any other key information
about the case study.
• Continue with the next 4 case studies in the same
manner.
• Consolidate the following points:
- A large number of maternal and neo-natal deaths
are avoidable or preventable.
- If the delivery is done at home, chances are that no
preparation is done prior to the delivery and the
birth attendant (either from the family or from the
community) is not well-trained.
- DeUvery at home may not always result in morbidity,
but that does not mean that home delivery is a good
option. In case of any danger sign or prolonged
labour, it would be difficult to manage at home.
- It is better to avoid the rush of a last-minute transfer
to the hospital if medical problems arise and choose
the option of institutional delivery.
- Institutions have round-the-clock help for the
mother and baby, for example, food, medical
assistance, and are able to quickly respond during
emergencies.
- Institutional delivery is one of the safest options
for the mothers-at-risk to address medical
complications and avert the possibilities of maternal
and infant deaths. Procedures such as caesarean
sections and forceps deliveries offer solutions to
dangerous situations that are available only at the
institutions.
~ It is important to convince the families to get
every delivery done at an institution, but especially
for high-risk cases, institutional delivery is the
only option.
~ Any danger sign requires immediate and
appropriate action.
~ To ensure availability at the time of delivery,
finding out what blood group the pregnant woman
is needs to be done in advance.
~ It is very important for the woman to stay at the
hospital/health facility for 48 hours to avail care
for herself and for the newborn baby.
~ This is a crucial period and ignorance/lack of
adequate knowledge about handling the newborn
can prove fatal.
• Use PPP to reiterate that at the institutions intra-natal
services are provided by trained and Skilled Birth
Attendants (SBA) that include the JHA, staff nurse
and medical officer.
• Inform them that the intra-natal care is available at
the same place where ANC is.
• Ask the participants to recall the facilities where
intra-natal services are available.
• Ensure that participants know the specific locations
where intra-natal services are available at all three
levels:
- Level 1 -SBA (SC, non 24/7 PHC)
- Level 2 - BEmONC (24/7 PHC, non-FRU CHC)
- Level 3 -CEmONC (FRU-CHC, TH, DH)
Core Concepts of Maternal Neonatal and Child Health 25
IMPORTANCE OF HOSPITAL DELIVERY
i Hands could be dirty
i in home delivery
■ In a hospital delivery
■ hands are covered
[ with gloves
Dirty cloth
Tying the
umbilical
cord with
dirty thread
Clean Thread
Tying the
umbilical
cord with
clean thread
v- -.f ill z •
Rusted blade
or scissors
Sanitized blade
and scissors
^Siwi
7
i-
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
3.2 STAGES OF LABOUR
• Inform the participants that there are four stages in the delivery process.
• Show the film on ‘Stages of delivering a baby’ which is available online, http://www.babycenter.in/vl027490/insidepregnancy-labour-and-birth
• https://www.youtube.com/watch?v=YlISC6KsYcc (National Geographic Documentary, ‘In The Womb’)
• Pause after each stage and explain the changed position of the baby and the process that is taking place.
• Explain that child birth is a very natural process and happens normally in most cases.
• However, some pregnant women in rural areas face several challenges during the entire phase of pregnancy/
delivery due to malnutrition and psychological pressures.
• Medical assistance by trained / skilled birth attendants can improve their chances of a normal/safe delivery.
• Use PPP to give an in-depth overview of a normal/safe delivery.
Stage 1:
Dilation
Amniotic fluid
within uterus
Cervix
Vagina
Undilated cervix
Stage 2:
Birth
(7) Presentation of head
(3) Delivery of posterior shoulder
Fully dilated cervix
(>10cm in diameter)
(2) Rotation and delivery
of anterior shoulder
(4) Delivery of lower body
and umbilical cord
Stage 3:
Afterbirth
delivery
Placenta detaches
and exits through
vagina
3.3 DANGER SIGNALS DURING THE
DELIVERY PERIOD
• Tell the participants that just as there are danger signs
that classify pregnancies to be high risk, there are also
danger signs during the delivery period.
• Ask the participants to brainstorm some danger signs
during delivery.
• Note their response on a flip chart
• Use PPP to explain the danger signals during delivery:
- Irregular/fast/very slow fetal heart beats1
(Fetal distress)
- Labour taking more than normal time in any stage
(Prolonged labour)
- Head or shoulders not coming out2
(Obstructed labour)
- Umbilical cord coming out before the baby
(Cord prolapse)
- Yellow or foul smelling liquor3 (Meconium stained
liquor)
- Placenta not expelled completely4 (Incomplete /
retained placenta)
- Fever
-Fits
A
• Use PPP to explain the technical terms that were used
in the film.
• Highlight that if any one of these signals is present
during the delivery period, it is important not to
wait for normal delivery. It is important for a doctor
to decide if the pregnant woman should have the
delivery by caesarean section and to take the doctor’s
advice.
• Tell them that waiting for normal delivery may
distress the baby and lead to physical/psychological
problems.
1 The normal range is 120 to 160 heart beats per minute
2 This could be result of different factors such as transverse
position or bigger size if the baby or small size of the pelvis/ cervix
not opening.
3 The foul smell indicates infections
4 If the placenta does not come and effort is made to remove it
forcibly, there is a danger to lead to hemorrhage
28 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
COMPLICATIONS DURING DELIVERY
Excessive bleeding
Core Concepts of Maternal Neonatal and Child Health 29
Process
complications delivery
should take place in
dhe hospital
Baby’s head and shoulder
not appearing first
4.1 IMPORTANCE OF PNC
• Give one of the case studies to each of the six groups.
Case 1
A five day old newborn had bleedingfrom his umbilical
cord. The grandmother applied some cow dung, a tradition
in many villages as people believe it has antiseptic
properties, to prevent the bleeding. But it did not stop.
Then she tied a piece of cloth around the cord and the
bleeding stopped. Afterfew days, the baby developed high
fever and there was pits on his umbilical cord.
3.4 THE '5' CLEANS
• Ask the participants if they can state the one key thing
that is critical for ensuring a successful delivery.
• Note their response on a flip chart.
• Focus on the term cleanliness.
• Tell them that cleanliness during the delivery process
is one of the most critical components for a safe
delivery process.
• Ask participants to identify most critical five things
that need to be clean for the safe delivery.
• Note their response on a flip chart.
• Consolidate the understanding by highlighting the
‘5’ cleans.
- Clean hands
w
- Clean delivery surface
- Clean cord cut
- Clean cord ties
- Clean cord stump care
• If the participant list other component that should be
clean during delivery, agree, but tell them the above
‘5’ deans are most critical.
• Consohdate the main points of Session 3:
- Knowing the advantages of institutional delivery
- Knowing the stages of labour
- Recognizing danger signs during delivery
- Importance of maintaining cleanliness
SESSION 3:
POST-NATAL CARE (PNC)
Training Materials
Laptop, LCD projector, screen and pointer, photocopies of Tool
3: Case studies for Post-natal care and PPP: Post-natal care
Tips for facilitators
The PNC period is one of the most critical periods in the
maternal and neo-natal care continuum. Many maternal and
infant deaths occur during this period. There are lot of
misconceptions around how, when and what to feed a newborn,
how to keep it warm, clean and safe. This session needs a
technical co-facilitator who is a senior medical doctor who
has MNCH experience and can emphasize the importance of
post-partum care. The RPs must understand their responsibility
to motivate the ASHAs to guide the nursing mothers and their
families to access health care at the nearest institution if there
are any danger signs.
e
Objective
• To help the participants understand post-natal
care (PNC) and its importance
- Importance of PNC
- Essential components of PNC
s
Methodology
Case study, small group
discussions and presentations in
plenary, PPP and discussion
Duration
3 hours
30 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Case 2
A newly delivered mother started breastfeeding her
baby after two days of delivery and therefore the baby
was not fed with the colostrum. She also did notfeed the
baby regularly. After ten days, the new mother began to
complain ofpain in her breasts. She also started running a
fever. She stopped feeding the baby as she felt that feeding
would increase her pain.
Case3
A grandmother started feeding a ten-day-old baby with
sugar water, honey and cow milk along with the breast
feeding as shefelt that exclusive breast feeding would not
help proper growth. A few days later the baby developed
loose stools and vomited profusely. The mother stopped
breast feeding thinking that it would increase the loose
motions and the baby was given only sugar water.
• Ask group members to read the case study in the
group, discuss and answer the questions below:
- What do you think had gone wrong or right in this
case?
- Why do you think this happened?
- How do you think this could have been averted?
- If everything is all right, then suggest what advice
you would give a new mother?
• Allow 15 minutes for discussion. Ask a representative
from each group to take 5 minutes to read out their
case study and share their responses to the discussion
questions.
• Ask other groups to share any other key information
about the case study.
• Continue with the next 5 case studies in the same
manner.
Cased
Kamala returnedfrom her mother’s house to her
husbands house five days after her delivery. Soon after
she started complaining of headache and blurred vision.
Her husband got her some tablets for headachefrom a
medical shop. Her headache subsided that day but came
back the next day. Her husband then took her to a local
quack who did not examine her but gave her some tablets
and ointmentfor headache, advising them to not to
worry. The next day, Kamala had convulsions and became
unconscious.
CaseS
Parvathi delivered their 3rd daughter. The first two
daughters were aged 4 and 2 years, lhe newborn baby
only weighed 2 kg. Both Parvathi and her husband were
disappointed at having another girl child, but decided
that they will try again and maybe have a male baby next
time.
Case 6
Bharati delivered at a PHC and returned home. Afterfour
days the JHA and the ASHA came to visit her at home.
She reported heaty bleeding. Both JHA and ASHA tried
to stop her bleeding but when it was not under control,
they called the ambulance (108) to take her to the nearby
facility. Bharati was taken to the PHC where the Medical
Officer gave her injections and tablets and the bleeding
soon stopped. _
• Consolidate the following points:
- Soon after child birth it is very important for
the mother to adhere to healthy and medically
appropriate practices for herself and her newborn
baby.
- The umbilical cord should be cut with a sterile blade
and tied with a clean cloth/clamp. The cord stump
must be kept clean and dry. It should be allowed
to dry naturally to prevent it from getting infected.
Nothing should be applied to the cord stump,
especially not cow dung. This could result into
infection/pus and further complications.
- The newborn and the mother should stay at the
institution for 48 hours. If they cannot stay, the JHA
and the ASHA should give them all the information
about caring for the mother and the newborn. They
must be told to contact the JHA or ASHA if there are
any problems, even seemingly simple/small problems.
Core Concepts of Maternal Neonatal and Child Health 31
- Exclusive breast feeding is best for the infant As
the mother continues to breast feed, more milk is
produced. The mother should not stop breast feeding
the baby even if there are signs of loose stools. If the
mother or family members feel that breast milk is not
sufficient, they should consult the JHA or the ASHA
to get help.
- If supplementary feeding is required, the mother
needs to know what, when and how the baby should
be fed and should contact the JHA or the ASHA
immediately to prevent infant from getting sick or
dying.
• Use PPP to explain that PNC refers to care of the
mother and the baby after the delivery, up to 6 weeks
(Le. 42 days).
• PNC care is an important component of MNCH as a
high proportion of deaths of mothers and newborns
take place during this period.
• Repeat some of the statistics about IMR data from
Session 1 and explain that good PNC can produce
better outcomes.
• Explain the importance of PNC visits and adhering to
the schedule. Home visits of the JHA and the ASHA
are scheduled on the 3rd, 7th and 42nd day after
birth for evaluation of the mother’s health, and on the
14th, 21st and 28th day for the newborn. These visits
are important to help the mothers understand the
importance of breast feeding, keeping the baby warm,
maintaining cleanliness and ensuring the completion
of the immunization cycle for the baby.
• These home visits also help to assess the overall health
conditions of mother and newborn and identify if
there are any danger signs or problems such as heavy
bleeding/infection. If there are problems, the ASHA or
JHA can recommend that the mother or newborn is
hospitalized.
• The home visits can also be used to provide appropriate
counselling and advice and referral to appropriate
clinics in case of any complications.
4.2 ESSENTIAL COMPONENTS OF PNC VISITS
• Use PPP to explain that the PNC visits should focus on
the following components:
• Assessment of mother and newborn
- The baby has to be given thermal protection and
ensure that the baby does not become either too cold
(Hypothermia) or too hot (hyperthermia).
- Explain the rationale behind keeping the baby warm.
- If the newborn is low birth weight (LBW) it should
not be bathed until it weighs at least 2.5kg as babies
below this weight are prone to hypothermia.
is the responsibility of the JHA and the ASHA. They
should check if any danger signs are present and if
so, call for immediate medical assistance to prevent
mortality and morbidity in both mother and infant.
- Use PPP to present the important danger signs in
mother and newborn.
- Highlight that LBW infants have low immunity and
their lungs are not fully developed. These infants
need special care, such as ‘kangaroo’ care.
- Use PPP to explain the advantages of‘kangaroo’ care.
• Advice and counselling
- The new mother and her family need guidance
on general health practices because there are
misconceptions about nutrition, cleanliness and
breastfeeding.
- Information is also needed about types of
immunizations, the prescribed schedule and birth
registration.
- Ask the participants to brainstorm topics on which
the ASHAs should provide advice and counselling.
- Note their response on a flip chart.
- Use PPP to ensure that all the topics are fully
explained.
Hardening of the breasts
Foul smelling discharge
from the vagina
iwelling I
; of the fad
g
■
a II ■ I
■
.............................................
■■
■
? head ache..... j
• Referral for complications
- If there are any danger signs/ complication the case
needs to be referred to the nearest health care facility
that offers an appropriate service.
•
■■
-
•
wer abdominal pain
• Consolidate the main points of Session 4:
- Importance of PNC
- Essential components of PNC
iffigl
g Burning
micturation
DANGER SIGNS IN THE NEWBORN MOTHER
’ Visit the health
center immediate!
k if danger signs are
v.
g
.
■
/—\
• Identification of danger signs in mother and
newborn
- Identifying danger signs during the post-natal period
32 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
'■
■■
.
■
■
■_
—
___ _____ _
DANGER SIGNS IN THE NEWBORN INFANT
■■
Fever
/
g' > Lf.:”
Zz:
wfgizyg,
Fits
Fever
i
X
Passing urine less
than six time in
‘ twenty four hours
SESSION 5:
CHILD CARE
Motions with blood
I
\ A/r
- -"
,Q. Objective
..
0
Case study, small group
discussions and presentations
in plenary, PPP and discussion
Duration
3 hours
Training Materials
I
Severe diarrhea
Methodology
f
• To help participants understand the last stage in the
MNCH continuum of care.
• The importance of proper child care.
• The importance and method of monitoring the growth
and development of a child.
• The causes of malnutrition and ways to prevent it.
• The causes of diseases and illness and how to prevent
and manage.
Lack of activity
Laptop, LCD projector, screen and pointer, photocopies of
Tool 4: Case studies; and PPP: Child care
Tips for facilitators
Child care is the last stage in the MNCH continuum of care.
Child care is crucial as most infant deaths occur during the
first 24 hours after birth and most children die within the
first year of their life. Wrong practices, misconceptions and
poor awareness about breast feeding, external feeding,
immunization and preventing/managing illness at this stage
can damage a child's health in the long run and need to be
corrected.
Process
5.1 IMPORTANCE OF CHILD CARE
• Define the last stage in the MNCH continuum of care
as child care.
• Tell the participants that a baby who is 0 to 1 year old
is referred to as an infant and from the first to five
years is referred to as a child.
Lethargy of hands
and legs
1
ill
Casel
Channu is an 8-year-old child studying in the 2nd
standard, He had mildfever, and weakness forfew days.
One day when he was playing he suddenly fell down
and could not stand on his feet He started crying. Some
friends carried him back to his home. When his parents
saw him they took him to the Taluk hospital. The doctor
said it might be polio. >
- .
>>
\ Lack of crying/
J
feeble cries
Redness of umbilical cord,
ypus from umbilical cord
Contraction
W* e "Z’ '
•K'
ofribs
Refusing to
breast fred
34 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
ft
• Explain that the period from year 1 to year 5 is very
important for the child’s future health. During these
years the growth and development of the child needs
to be monitored closely to prevent long term health
problems.
• Give one of the case studies to each of the five groups.
fifteen days, the cough andfever worsened, but they still
continued with the remedies at home without consulting
a doctor. When the baby became very ill they rushed him
to a doctor. The doctor said the baby's condition was very
serious and they should have brought him much earlier.
Cased
Gayathri,a 2-month-old baby, had been having watery
stoolsfor 3 days. She was not fed properly due to the
illness. When the baby didn’t pass urine the whole night,
the next morning thefamily approached the fHA at the
SC. Seeing the baby’s condition, the )HA referred the baby
immediately to the FRU as she decided that the baby
required glucose (IVfluids).
Case2
Shilpa and Aishwarya were sisters married into the same
family. After one year, both ofthem gave birth to one
child. The elder sister, Shilpa was beauty conscious and so
she stopped breastfeeding the baby very early andfed her
child with a bottle. Aishwarya, the younger sister preferred
to breastfeed her baby. As the children grew, Aishwarya's
baby, which was breastfed longer, was healthier than
Case 5
Rafi^ is an 18 month old boy who was severely
Shilpa’s bottle-fed baby, who frequently suffered infections.
underweight. Rafay was not being breastfed, but given
Case3
A 2-year-old baby was suffering with cough, fever and
difficult breathing. His grandmother tried to treat him
with home remedies using basil leaves and honey. After
roti, dal and vegetables. He eats about half to one roti
thrice a day. His mother complains dial he does not
eat a lot and has very poor appetite. He hasfrequent
episodes of re^iratory infections, but no other illness. His
immunization schedule is complete.
Core Concepts of Maternal Neonatal and Child Health 35
• Ask group members to read the case study in the
group, discuss and answer the questions below:
- What is the health problem affecting the child?
- What do you think caused the problem?
- What could be done to improve the child’s
condition?
• Allow 15 minutes for discussion. Ask a representative
from each group to take 5 minutes to read out their
case study and share their responses to the discussion
questions.
• Ask other groups to share any other key information
about the case study.
• Continue with the next 4 case studies in the same
manner.
• Use PPP to explain all issues raised in detail:
- Dehydration is a serious condition and the child
needs immediate medical care. To prevent the child
being dehydrated, it is important that it is given
enough liquids, especially when the child loses fluid
due to vomiting/diarrhoea.
- Continuing breastfeeding for as long as possible
is very important for a young child. Breast milk is
the ideal food as it contains a mix of enzymes and
antibodies, making breastfed children less likely to
have diarrhoea, ear infections, respiratory illness,
allergies, intestinal worms, and colds. Extended
breastfeeding can also reduce the risk of breast
cancer.1
- Some home remedies can be helpful, such as a
mitigating measure for minor illnesses, but only
using home remedies in the case of severe infections
can be dangerous. Consulting a qualified medical
doctor at the earliest time can reduce serious illness.
- Mothers need to have correct information and
knowledge about basic nutrition and how the right
foods can ensure proper growth during all the
developmental stages of the child. Mothers need
to know who to contact so they can access this
information.
- The mother and family should also know that the
child care health services are expensive in private
hospitals, while in government hospitals MNCH
child care services are available at a cheaper rate.
- It is important to immunize the child according to
the prescribed schedule of required vaccinations.
Otherwise the health of the child, and the
community, could be compromised.
- When a child has episodes of diarrhoea it is
important to continue to provide food and liquids.
Give boiled and cooled water, warm and fresh foods,
but avoid fatty foods.
1 Collaborative Group on Hormonal Factors in Breast Cancer;
Lancet, 2002 Jul 20; 360 (9328): 187-95
• Highlight the fact that if there are any problems,
MNCH child care services can control illnesses and
diseases.
• Ask the participants to recall the facilities where child
care services are available.
• Ensure that participants know the specific locations
where child care services are available at all three
levels:
- Level 1 -SBA (SC, non 24/7 PHC)
- Level 2 - BEmONC (24/7 PHC, non-FRU CHC)
- Level 3 -CEmONC (FRU-CHC, TH, DH)
5.2 CAUSES OF CHILD DEATHS
• Ask participants to brainstorm the direct causes of
child deaths.
• Note their responses on a flip chart.
• If these causes are among those which are included
in the top three causes, congratulate them for their
understanding.
• Otherwise tell them that all the causes they listed do
lead to child deaths, but are not among the top causes.
• Use PPP to show to highlight the top causes are as
follows:
- Neonatal conditions (33%)
- Pneumonia (22%)
- Diarrhoea (14%)
- Highlight that pneumonia and diarrhoea are both
common causes of child morbidity and mortality,
but are avoidable with appropriate hygiene (washing
hands with soap and water before eating and after
defecation).
5.3 GROWTH AND DEVELOPMENT
• Use PPP to explain that regular growth monitoring
helps in checking whether the child’s growth and
developmental milestones are appropriate for its
age. It also helps in early detection and subsequent
mitigation of any physical handicaps found in
children, such as vision and hearing loss.
• Explain that the growth and development depends
upon several inherent as well as external factors.
• Ask participants to brainstorm what factors could
affect growth and development.
• Note their responses on a flip chart
• Use PPP to emphasize that when delayed growth
and development indicators are identified, then early
referral to an appropriate health care provider can
prevent more serious or future complications.
• Tell them that the AWW plots the growth of the child
on a graph chart which helps diagram and illustrate a
child’s developmental progress.
• Display the proto type of the growth chart (See
background material) and outline the parameters of
growth and the normal values at different ages.
• Explain what the green, yellow and red bands on
36 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
the growth chart mean. The red band shows severe
malnourishment, yellow moderate malnourishment
and green shows no malnourishment.
5.4 PREVENTING MALNUTRITION IN
CHILDREN
• Show a picture of malnourished children to help
participants understand how malnutrition affects a
child’s growth and development indicators.
• Use PPP to explain the key messages to prevent
malnutrition.
• Highlight the importance of exclusive breast feeding,
complementary feeding, feeding during illness,
prevention of illness and access to health care and
AWW services.
5.5 PREVENTION AND CONTROL OF
DISEASES
• Ask the participants if they agree that children are
more prone to diseases than adults.
• Note their responses on a flip chart.
• Some illnesses, which are not usually fatal if
diagnosed early and treated properly, are diarrhoea,
the common cold and acute respiratory infections
caused by a number of respiratory viruses.
• Tell them that low immunity levels are the major
cause of diseases. Immunity levels can be affected by
different factors and practices. Though many of these
diseases are dangerous they can be prevented to a
large extent if the child is immunized. These diseases
are called ‘Vaccine preventable diseases’ (VPDs).
• Explain that immunization is one of the most wellknown and cost effective methods of preventing
diseases. However, immunization has to be sustained
to prevent VPDs.
• Ask the participants to brainstorm common vaccine
preventable diseases.
• Note their responses on a flip chart.
• Share the list of the six most common vaccine
preventable diseases:
- Tetanus
- Poliomyelitis
- Diphtheria
- Pertussis (whooping cough)
- Measles
- Childhood tuberculosis
• Stress that the vaccines must be given at the right age,
right dose, right interval and the full course must be
completed to ensure the best possible protection to
the child against these diseases. The schedule that tells
us when and how many doses of each vaccine are to
be given is an immunization schedule. If a child is
not given the right vaccines in time, it is necessary to
get them started whenever possible and complete the
primary immunization before the child reaches its
first birthday.
• Present the national immunization schedule and
emphasize that the booster doses are essential.
• Highlight that for school admission a certificate of
complete immunization is required.
SESSION 6:
CRITICAL MNCH ISSUES
J®, Objective
Tips for facilitators
• To review the MNCH continuum of care
• To identify seven issues that are critical to a MNCH
intervention
Methodology
Duration
Small group discussion and
plenary presentation and
discussion
1 hour
In this session the participants will review the different
stages of the continuum of care and shortlist key themes
that are critical to ensure the health of the mother and
child. These key themes will form the key messages for a
MNCH intervention. Although all issues are important, the
participants will need to prioritize the most crucial issues for
the intervention. The facilitator needs to help participants
through this process of analysis.
Training Materials
Markers and brown sheets/ card sheets
Core Concepts of Maternal Neonatal and Child Health 37
4^ Process
6.1 SEVEN CRITICAL ISSUES
• Ask participants to recall the stages in the continuum
of care:
- Antenatal care - care during pregnancy
- Intra-natal care - care during the delivery and first
two hours after the delivery
- Postnatal care (Mother and newborn) - care during
the first 42 days
- Child care - care of the child till year 5.
• Divide participants into these four groups.
• Ask each group to list the major issues in each stage
on a flip chart.
• Allow 15 minutes for discussion.
• Ask a representative from each group to display their
flip chart on the walls of the training room and to
take 5 minutes to share their answers.
• Continue with the next 3 groups in the same manner.
• Ask all the groups to now consolidate all of the issues
that have been identified by all the four groups and
to pick the 7 most critical issues for the Sukshema
project’s MNCH intervention.
• Allow 10 minutes for each group to list the 7 most
critical issues on a flip chart and then to display their
flip chart on the walls of the training room.
• On a clean flip chart the facilitator should list the
common most critical issues from each group. Use
tally marks to decide in what order they are ranked.
• If there are disagreements about some issues, discuss
with the group. Come to an agreement on 7 issues.
• Now display the list of 7 critical issues that have been
identified by MNCH experts.
• Ask the group to compare their list with the list
compiled by experts as follows:
- Birth planning: This includes ensuring registration,
receiving information about importance of
institutional delivery, having JHA and ASHA contact
numbers, arranging money and transport to go
to the health care facilities, knowing blood group
and arranging for blood before delivery, arranging
clothes for the baby and preparing a care taker to
accompany and care for the pregnant woman.
FAMILY PLANNING
|
- Nutrition: Importance of having nutritious food
that include vegetables, fruits, sunflower or sesame
seeds, supplemented by iron and folic acid tablets
(normally 100 but 200 in case of severe anaemia),
avoiding drinking too much tea or coffee, and
maintaining basic hygiene at key times (washing
hands before eating, after defecation and washing
fruit/vegetables before eating).
blood loss
4
Difference of three year
between the first child
and the second child
- Family Planning: Indudes counselling on birth
spacing and family planning methods appropriate to
the profile and need of the pregnant woman.
- Danger signs: Recognizing danger signs for mother
and newborn during ANC, INC and PNC and
knowing what to do/who to refer to.
Condoms
- Newborn care: Includes kangaroo care, breast
feeding, thermal protection, the 5 ‘deans’, umbilical
cord care, and giving the needed support to adjust to
the new environment
Mala D table
?T;
CopperT
Operation [male)
|
?
.
- Government schemes: Information on government
schemes, both state and central government that
are MNCH related, with focus on Madilu Kit, Bal
Sanjivini, Thai Bhagya, JSY and Prasooti Arayike.
y
.
k‘.
b
Operation [female]
J
V
- Patients’ Rights: Information about available health
services and instilling a rights perspective among
women in accessing the health care services in line
with their needs.
W _l
L
• Tell the participants that these identified 7 critical
issues will form the activities of the Sukshema
projects MNCH intervention.
' '• ■ • ; .
A.
' '
A baby girl isth<
light of the famih
..
to
T. / A
Birth spacing important
’■S
Core Concepts of Maternal Neonatal and Child Health 39
NEWBORN CARE
\
w
X
Feed only breast milk for
first six months feed
Baby should be wrapped
and kept warm
Do not apply
anything into
the eyes and
I ears of the
'
baby
Do not apply anything
on the umbilical cord
*lhe first tuiusirum should be fed Lu the baby
Breastfeed 8 to 10 times i
Clean the breast before
breast feeding
24©
I ____
Cleaning the
newborn with
/ a clean cloth
without giving
a bath
Vaccination to
be given as per
|the advice of the
doctor
!5aiSS5
I
................
Right positions to breast feed
I
Follow the right way of
breast feeding
With appropriate
care the infant can be
saved from risk
J
Baby should sleep
next to mother
Kangaroo care
40 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Vaccinations
=f-
SESSION?:
POST-TEST
AND TRAINING
EVALUATION
AND FEEDBACK
Objective
TRAINING EVALUATION AND FEEDBACK FORM;
KARNATAKA HEALTH PROMOTION TRUST
Training Evaluation and Feedback Form
S.No.
Process
• To assess the extent to which the participants
have understood the sessions' key messages.
• To assess what affect the module had on the
participants' attitudes, knowledge and practice
levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for
enhancing future effectiveness.
Methodology
Duration
Reflection
30 minutes
Training Materials
Annexure 6 Post-test and Training evaluation
and feedback form
Tips for facilitators
The post-test: will assess the extent to which
the participants have understood the sessions'
key messages. The seating arrangements can be
changed to ensure that each participant does
their own work so as to gauge how well they have
understood the technical components and terms
described through the module's sessions. This post
test can be modified based on the local training
context. The post-test feedback can be either
through sharing the marked tests, or through a
group discussion about the best possible answers
for each questions.
The training evaluation and feedback form:
will assess what affect the module had on the
participants' attitudes, knowledge and practice
levels and obtain feedback on the usefulness of
the training and suggestions for enhancing future
effectiveness.
• Assign a new ‘classroom-like’ seating arrangement for the
participants, having them sit in rows that allow a space
wide enough for the facilitator to walk through.
• Reassure them that this post-test is not for grading
purposes, but to gauge the extent to which the training has
been successful in highlighting the key themes and
technical content.
• Give each participant a post-test and ask them to put their
name at the top.
• Allow 20 minutes to complete it by choosing one correct
answer from the multiple choices.
• After they finish, collect the filled questionnaires.
• Distribute the training evaluation and feedback form. Go
over all the areas that they will need to think about while
filling it in.
• Allow 20 minutes to complete it.
• While participants are completing the training evaluation
and feedback form, the facilitators of the module should
check the post-test papers and total the marks for each
participant
• Decide if the post-test results will be shared with the
participants, or if a group discussion will be held on the
correct answers.
• Collect the training evaluation and feedback forms from
the participants.
• Either give back the post-tests and go over the correct
answers, or hold the group discussion on the correct
answers.
• Before the closing ceremony, ask the participants to share
their feelings about the training: encourage anyone who is
keen to orally share two positive aspects and two areas that
need improvement.
• At the closing ceremony thank all the participants for their
enthusiastic participation, congratulate them and wish
hem the best as they go back to their own work areas and
begin to initiate the intervention on the ground.
• Thank everyone else who contributed to the training
program. This might have included administrative staff,
venue owners, facilitators, guest speakers and the organizers.
42 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Place of training:
Designation;
Name:
Training dates:
Name of the PHC:
Excellent
Subject
1
Training content and sessions
2
Training methodology and activities used
3
Training skills of the facilitators
4
Logistics at the training (Food, stay and comfort)
5
Relevance and usefulness of training
Good
Poor
List the three aspects of the training that you found most useful.
1.
2.
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
1.
2.
3.
What are the three most important lessons that you can take back to your work place from this training?
1.
2.
3.
Please list suggestions for improved facilitation in future trainings.
1.
2.
3.
Core Concepts of Maternal Neonatal and Child Health 43
ANNEXURE 1 - Reading material
on MNCH continuum of care
INTRODUCTION
Adopted by world leaders in the year 2000 and set
to be achieved by 2015, the MDGs provide concrete,
numerical benchmarks for tackling extreme poverty
in its many dimensions and provide a framework for
the entire international community to work together
towards a common end - making sure that human
development reaches everyone, everywhere.
in
Two of the health-related MDGs focus on reducing child
mortality and improving maternal health. The global
data substantiates provides the rationale for its inclusion
in the MDGs. It says Worldwide:
• 530,000 women die from pregnancy related
complications
• 4 million babies die within first month of life
• More than 10 million children die under age 5
• Nearly 99% of mother, newborn and child deaths
occur in low and middle income countries
Most of these deaths are preventable if proper and timely
care is made available. If we further analyse the data it
shows that most of the deaths occur during the first five
years: of which most happens in the first 24 hours.
Therefore, the MNCH programme under the NRHM,
is envisaged to address complications during pregnancy
and dehvery and during neonatal and first five years,
as universal coverage with key effective, affordable
interventions: care for newborns and their mothers;
infant and young children.
is critical to the health of both the woman and the
newborn child and is based on the assumption that
the health and well-being of women, newborns, and
children are closely linked and should be managed in a
unified way.
WHY THE APPROACH IS ESSENTIAL?
In the absence of the continuum of care approach,
the policies and programs in the fields of maternal,
newborn, and child health, would generally focus on
one issue alone and address it with reference to only
one of these groups. This approach would result into
obscuring important linkages. When approached
together and incorporated into integrated programs,
these interventions can offer continuity of care and save
millions of fives by building linkages, reducing missed
opportunities, minimizing delays in care and treating the
components as a continuum rather than separate parts.
This approach that groups the interconnected fields of
maternal, newborn, and child health can help families
access the benefits more easily. Linking interventions
and delivering it as a package within the continuum of
care can also avoid the duplication and make it more
cost-effective. It thus can have a stronger impact and
accelerate progress to improve the lives of families.
-J
ANC is the medical care given to a pregnant woman and
her baby starting from the time of conception up to the
delivery of the baby and even goes beyond it. It plays
an important role in achieving the aim of MNCH by
preparing the pregnant women for a successful labour
and delivery process by helping the mother maintain
good health during pregnancy, informing the family
members about pregnancy, labour and child care.
Pregnancy is a natural event in the life of women of
reproductive age group. However, during pregnancy and
childbirth some problems may arise which can threaten
the life of the mother, baby or both. It is possible to
identify women with some problems quite early if
they have routine ante-natal check-up. This will enable
them to access specialist care. Care during pregnancy
is important to monitor progress and growth of the
baby, detect complications at the earliest and treat them
accordingly. During the visit the woman and her family
should be advised proper nutrition, rest, exercise. They
can make plans about where to deliver. This will help
both the woman and baby to have a happy and healthy
outcome. Minor ailments of pregnancy (e.g. vomiting,
heart bum, constipation, backache etc.) are looked after
during ANC period.
SCHEDULE OF ANC
WHAT DOES IT INCLUDE?
The MNCH services under NRHM have adopted the
continuum of care as one of its guiding principles to
bring needed interventions to mothers, newborns, and
children to improve their health and survival by saving
children who die every year from preventable diseases.
WHAT IS CONTINUUM OF CARE?
Continuum of care is a concept involving an integrated
system of care that guides and tracks patient over a
period through an intensive and comprehensive array of
health services spanning the entire lifecycle from ‘start
to finish’ in a seamless manner rather than a specific and
unvarying list of services.
ANNEXURE 2 - Reading material
on antenatal care (ANC) -ajF
This model demands the availability and accessibility to
essential healthcare services and includes a package of:
• Antenatal Care - care during pregnancy
• Intra-natal Care - care during delivery of the baby
• Post-natal Care - care during the period starting
from dehvery up to 6 weeks
• Child Care - care of the child up to 5 years
WHAT IS MNCH CONTINUUM OF CARE?
The ‘MNCH Continuum of Care’ includes integrated
service delivery for mothers and children from
pregnancy to delivery, the immediate postnatal period,
and childhood. It recognizes that safe childbirth
44 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• The first visit is recommended as soon as the
woman feels that she is pregnant. This is called
registration of pregnancy, which ensures that
all pregnant women receive care throughout
pregnancy.
• In villages/districts where female foetuses are being
eliminated before birth, it is further important that
pregnancy is registered early.
• The second visit should be made between the fourth
and sixth month.
• The third visit should be planned in the eighth
month.
• An additional visit in the ninth month would help
provide better care.
If the health worker identifies health problems during
these visits, a visit to a doctor will become necessary.
Advantages of early registration:
• Helps in assessing the health status of the mother and
-
■
obtaining baseline information on BP, weight, etc.
• Helps in screening for complications/danger signals
at an early stage and managing them appropriately by
referral as and where required.
• Helps the woman recall the date of her last menstrual
period for deciding EDD
• Helps in giving the woman the first dose of Tetanus
Toxoid (TT) injection well within time (after 12 weeks
of pregnancy).
• Helps the pregnant woman access facilities for an early
and safe abortion if she does not want to continue with
her pregnancy.
• Helps in building a good rapport with the pregnant
woman and her family.
• Helps in starting the woman on a regular dose of folic
acid during the first trimester.
• Helps in maintaining complete records in the Thayi card
and for follow up.
What is done during pregnancy check-up and care?
A complete pregnancy check-up is carried out to detect
problems and decide whether referral to doctor is required.
During thefirst check-up
• Take complete history of this pregnancy and previous
pregnancies, if any and whether the woman has had any
medical/surgical problem in the past.
• Weigh pregnant woman to see whether she is gaining
adequate weight during pregnancy.
• Check BP to see if it is normal, high or low.
• Exam breasts/nipples to check whether they are normal.
• Exam abdomen to check growth/position of the baby.
• Test blood for anaemia (lacks blood/haemoglobin).
If anaemic, how severe? If the woman has anaemia,
prompt treatment helps prevent complications.
• Examine urine.
• Give first dose of TT injection.
During subsequent visits
• Details of any problem appearing since last visits are
reassessed.
• BP, weight, and abdominal examination are repeated.
• Hundred iron and folic acid tablets (IFA) are given to all
pregnant women.
• Treatment for anaemia depending upon the blood test
results.
Core Concepts of Maternal Neonatal and Child Health 45
• Health education, advice, and counselling on
- Nutrition
- Birth planning
- Safe abortion
- Family planning
- Institutional delivery
- Information about government schemes such as JSY,
Madilu Kit, Prasooti Araike.
HIGH RISK PREGNANCIES
It is important to identify the high risk pregnancies, with
risk either to the mother and baby, and monitor them
regularly by visiting them every month, watching for
danger signals and convincing them to go for regular
check-ups at the hospital and have an institutional
delivery.
Thefollowing are considered high-risk pregnancies:
• Severe anaemia -possible need for blood transfusion
during delivery.
• Young primi1 (below 18 years) - possibilities of
complications if the reproductive system is not
fully developed (obstructed labour, ante-partum
haemorrhage).
• Elderly primi (above 30 year) - there is risk of
diabetes / High BP, chance of handicapped children.
• Elderly grand multiparas2 - possibility of increased
incidences of complications during pregnancy, labour
and puerperium are likely to occur in these women.
• Short structured primi (140 cm) -There can be higher
incidences of preterm birth and underweight babies.
Also, these women are more likely to have a small
pelvis, which can result in such complications during
childbirth.
• Mal-presentations, (breech, transverse lie) etc. - Mal
presentation or mal-position of the foetus at full term
increases the risk of obstructed labour and other birth
complications.
• Ante partum haemorrhage, threatened abortion
(bleeding) - chance of pre-term delivery.
• Pre-edampsia & eclampsia.
• Twins, hydramnios.
• Previous C section or instrumental delivery/
prolonged labour/ stillborn/ intrauterine death/
manual removal of placenta/PPH.
• Excessive weight gain or not gaining enough weight.
• Family history of systemic illness - hypertensive,
diabetes, h/o thalassaemia, delivery of twins and
delivery of an infant with congenital malformation.
• Pregnancy associated with general disease.
1 Primi is a woman who is going to be delivering the baby for the
first time
2 The term "multipara" applies to any woman who has given birth
2 or more times. A woman who has given birth 5 or more times is
called a grand multipara.
• History of intake of habit-forming or harmful
substances, such as alcohol, cigarettes.
Pregnant women with any ofthefollowing conditions
has to be referred to a doctor
• Repeated neo-natal deaths, stillbirths, premature births
or repeated abortions.
• Vaginal bleeding during present pregnancy.
• High BP or abnormal urine test indicating pregnancy
induced hyper-tension (PIH).
• If the pregnant woman’s previous delivery was through
abdominal operation or she has had some other
abdominal operation in the past.
• The pregnant woman has heart disease, anaemia, high
BP, jaundice etc.
• If the pregnant woman has very big abdomen.
• If the woman is pregnant with twins.
• If the baby is upside down or in abnormal position
inside the uterus.
Home care during pregnancy
• The woman’s family and community have the key
responsibility for making sure that the woman gets
more food, takes rest and does not have to do heavy
manual work during pregnancy.
• The pregnant woman needs extra energy from food,
for the sake of her own health, for the growing foetus
and for effective breastfeeding later on.
• During pregnancy a nutritious diet which is rich
in iron, calcium and protein is required. For this, a
pregnant woman should eat green, leafy vegetables,
dal, milk, jaggery, eggs, fish, meat, etc.
• Taboos and restrictions on a pregnant woman’s diet,
such as not allowing certain vegetables, fruits, milk and
ghee, might in fact harm her and the baby.
• Pregnant women are entitled to get food from the
AWW centre.
• A pregnant woman should not fast. This deprives her
and the growing baby inside the uterus of essential
food.
• Pregnant women should not carry out heavy manual
labour, like working on construction sites, famine
relief, brick kilns, etc. Other members of the family and
community should help to reduce her work burden.
• Pregnant, adolescent girls are especially likely to
be under-nourished and are more likely to suffer
problems during delivery. They need extra nutritious
food and help for safe delivery at a health facility.
• Sometimes there are overweight pregnant women who
need to avoid eating fat-rich food like oil, ghee, sugar,
etc), but they should continue to eat vegetables, fruits,
nuts and milk which are rich in iron, calcium, vitamins
and minerals. They should also take regular exercise
and consult a doctor.
46 Community Level interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
EMERGENCY REFERRAL DURING PREGNANCY
Danger signs in women
How to recognize
Action to be taken
Bleeding from the vagina
Bleeding- Any amount (bright red
bleeding, or clots or tissue)
Refer to FRU/ Dist/ tertiary hospital
Loss of foetal movement
Absence of movement or kicking
Refer to FRU/ Dist/ tertiary hospital
Headache/ dizziness/ blurred
vision
Severe headache and blurred
vision or severe headache and
spots before the eyes
Refer to FRU/ Dist/ tertiary hospital
Swollen face/ hands
Pitting oedema over back of the
palm
Refer to FRU/ Dist/ tertiary hospital
Convulsions/ fits
Eyes roll, face and limbs twitch,
body gets stiff and shakes, fists
clinched
Refer to FRU/ Dist/ tertiary hospital
NON- EMERGENCY REFERRAL DURING PREGNANCY
Problem
How to recognize
Action to be taken
Severe anaemia
Tongue very pale, weakness,
general swelling on body
Refer to PHC/ dist/ tertiary hospital
Night blindness
Pregnant woman finds it difficult to
see at dusk
Refer to JHA or PHC
Fever
Skin warm to touch. Temp > 100'C
Give paracetamol tab. If no relief
after 48 hours, refer to PHC
Pain/ burning during urinating
Frequent urination & urgency, or
pain/ burning when passing urine
Have mother drink two glasses of
water in the morning, afternoon
and evening. If no relief after 24
hours, refer to PHC
White discharge
Passage of white discharge by
Vagina, itching in private parts
Teach mother to use genital violet;
placed high in her vagina daily. If
no relief after 5 days, refer to PHC
Itching/ scabies/ boil with pus on
skin
Skin rashes with itching- could be
present in other family members
as well
• Scabies
• Presence of pus filled boils
For boils, advise woman to apply
hot fomentations to the area thrice
daily. If no improvement after 2
days refer to PHC
Bad obstetric history
Past history of abortion, still birth,
neonatal death
Refer to FRU/ dist/ tertiary hospital
Multiple pregnancy
Suspicion/ knowledge
Refer to FRU/ dist/ tertiary
Malpresentation
Suspicion/ knowledge
Refer to FRU/ dist/ tertiary
Core Concepts of Maternal Neonatal and Child Health 47
Anaemia in pregnancy
• Lack of blood in the body is known as anaemia and
is common in northern Karnataka. Anaemia in
pregnancy leads to complications in pregnant women
and can result in the death of mother and baby. A
pregnant woman with anaemia looks pale, feels tired,
complains of breathlessness on carrying out routine
work, and might have swelling of the face and body.
Anaemia can be prevented and treated completely if
the woman follows the advice of JHA/doctor.
• Anaemia is treated with iron tablets, which have to
be taken daily for many months during pregnancy
or by giving injections. If the anaemia is severe,
hospitalization and blood transfusion may be
required.
• All pregnant women need to take one iron tablet
daily, starting after three months of pregnancy to
prevent anaemia.
• While giving iron tablets, the woman should be
advised that some side effects might occur. However,
they can be managed. These include:
- Nausea or occasional vomiting - this can be
prevented/avoided by taking the tablet after meals.
- Constipation - this can be managed if the woman
drinks more water and eats fruit
- Black stools or mild diarrhoea.
• The pregnant women should be advised that iron
tablets should not be taken along with tea as that
reduces its absorption.
• Pregnant women who have anaemia must have
deliveries in hospital.
KEY MESSAGES
• All pregnant women should have early registration
(12-16 weeks)
• All pregnant women should have a minimum of three
ANC check-ups and hospital delivery in a health
centre or hospital.
.. ..J
L.
.
4
HQW TO PREVENT ANAEMIA
■
Consumption of
irsn tablets '
48 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
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■
•
ROLES AND RESPONSIBILITIES OF ASHA:
• Visit every house in the community to make a list of
all women who are eligible to become pregnant and
children under the age of 5 years.
• Keeps records, registers and stock of supphes,
equipment and medicines.
• Identify all pregnant women in the respective villages
• Help pregnant women in getting registered between
12-16 weeks of pregnancy and in getting the next
three ante-natal check-ups.
• Ensure all requisite examinations/investigations are
done for all pregnant women.
• Know the date and time of availability of JHA in
Anganwadi Centre (AWC) in your village and inform
all pregnant women about the same.
• Advise pregnant women regarding importance
of balanced diet and ensure that undernourished
pregnant women receive supplementary food from
AWC.
• Attend to home deliveries and observe each woman
during labour and delivery
• Recognizes early signs of newborn’s sickness and
manages it at home.
• Ensures that the baby gets necessary immunization
on time.
• Actively collaborates with traditional birth attendant,
JHA and supervisor.
• Track the drop-out pregnant women especially those
who live in remote areas, are below poverty line,
schedule caste/schedule tribe/migrants, etc. and help
them in accessing health services.
• Help eligible pregnant women to get benefits under
JSY.
• Advise the pregnant woman and her family about
potential danger signs during pregnancy, delivery
and after delivery, the post-partum period. If she has
any of the following problems, she should be taken
immediately to the nearest functional FRU directly.
These include:
- Any vaginal bleeding during pregnancy
- Heavy vaginal bleeding during and following
delivery, especially if the woman is feeling weak and
faint
- Severe headache/blurring of vision
- Convulsions or loss of consciousness
- Labour pains lasting more than 12 hours
- Labour pains before eight months or 32-36 weeks of
pregnancy.
- Premature rupture of the bag of waters or leakage of
water from uterus membranes, leaking
- Failure of the placenta to come out within 30
minutes after delivery
- Baby stops kicking inside the womb
ASHA should have thefollowing information:
• The location of nearest FRU/hospital with
obstetrician, anaesthetist, paediatrician, nursery, O.T.
and blood bank.
• The mode oftransport to reach facility should there
be an emergency
• Approximate cost for Caesarean Section, blood
transfusion and hospital stay, if it is a private hospital.
Note:
In cose, it is a second pregnancy, when a couple
already has a daughter, ASHA needs to be alert to the
possibility that the family may reject another daughter
and counsel accordingly.
ROLES AND RESPONSIBILITIES OF JHA:
• Cooperates with ASHA and informs her when women
go into labour
• Attends to mothers during labour and delivers babies
• Practices clean and safe dehvery methods
• Reinforces health education messages given by ASHA
Core Concepts of Maternal Neonatal and Child Health 49
ANNEXURE 3 - Reading material
on delivery/ intra-natal care
WHAT IS INTRA-NATAL CARE?
Intra-natal care refers to the process of child birth. It
is an extremely important process in every pregnancy.
Quality intra-natal care can be the key to control the
maternal mortality problem in India.
Delivery occurs normally after nine months of
pregnancy. If delivery is before time special care for baby
may be needed. As far as possible a pregnant woman
should have the delivery in a health centre or hospital
even if pregnancy is normal. This is mainly because
during delivery, labour complications may suddenly
occur which can threaten the life of mother, baby or
both.
During delivery the time between starting of a problem
to death of mother, baby or both is so short that it may
not be possible to save the life of mother or baby if the
pregnant woman is not already in a well-equipped health
centre or hospital.
• Safe delivery with minimum injury to the infant and
mother
• Preparedness to deal with complications such
as prolonged labour, ante-partum haemorrhage,
convulsions, mal-presentations and prolapsed of
umbilical cord etc.
• Care of the newborn baby
The intra-natal care includes
• Observation and assessment of the woman in labour,
observation of the foetus, monitoring of labour,
observation of the newborn in terms of appearance,
pulse/ heart rate, reflexes, activity and muscle tone and
respiration and weight recording.
• Care and attention in terms of prevention of infection,
establishment of respiration of the newborn,
prevention of heat loss and cutting of umbilical cord of
the newborn.
• Education and counsel to feed colostrums, and develop
an immediate bond between the mother and the
newborn
DANGER SIGNALS DURING INTRA-NATAL
PERIOD
It is important to identify danger signals and refer the
woman in labour to the appropriate health care facility
especially in case of the home deliveries. These danger
signals include:
• Irregular / fast / very slow fetal heart1 (Fetal distress)
• Labour taking more than normal time2 (Prolonged
labour)
• Head or shoulders not coming out (Obstructed
labour)
• Cord comes out before baby (Cord prolapse)
• Yellow or foul smelling liquor (Meconium stained
liquor)
• Placenta not expelled completely (Incomplete /
retained placenta)
• Fever
• Fits
1 The normal range of baby's heartbeats is 120 to 160 heart beats
per minute
2 An ’average' length of labour for a woman having her first child is
12 to 18 hours. An "average" length of labour for a woman having
her second or more children is considered to be about 7 hours.
If the labour period extends to more than 24 hours, it is called a
prolonged labour.
ROLES AND RESPONSIBILITIES OF ASHA:
• Counsel/advise the pregnant women and their
families for institutional delivery.
• Identify the location of the hospitals, health centres,
institutions near your village which provide delivery
services round the clock, where delivery can take
place and the cost for the same, if any and how to
reach the hospital.
• Escort/ accompany the pregnant woman to the
hospital for institutional delivery.
• Ensure the availability of transport to the FRU/
transport money available for the same, and how to
access it in case of emergency and escort her.
• Find out the money/other provisions available under
JSY for the area/ and what is the procedure to get it
• If there is no functioning health centre or hospital
within reach, or the family prefers a home delivery,
advise the pregnant woman and her family to have
the delivery conducted at home by a skilled birth
attendant (SBA) such as JHA, staff nurse or doctor.
• In case a skilled birth attendant is not available, the
delivery can be conducted by a trained TBA.
• Five cleans must be practiced during delivery: i.e.
Clean hands. Clean surface, Clean new blade. Clean
cord tie and Clean cord stump (do not apply anything
on the stump).
• Place of delivery to be kept warm and free from
draught.
• Help the mother in initiation of breast-feeding
after delivery.
OBJECTIVE OF INTRA-NATAL CARE
Intra-natal care aims to provide
• Maintain the health and well-being of pregnant
women and their offspring during the intra-natal
period
• Closely observe the women in labour and avoid
interference with natural process of delivery unless
there is a valid reason to do so.
• Encourage and support women in labour and extend
personal attention to them.
• Identify promptly any complications during the
delivery process and institute immediate remedial
measures including referral care.
• Ensure a safe delivery outcome in the form of healthy
mothers and healthy babies.
STAGES OF LABOUR
1st stage- Starts from the beginning of pain until the
mouth of the womb is fully open. This happens inside and
cannot be seen. The bag of water also breaks. The fluid is
usually clear but could also be yellow, green or red. This
stage of labour usually lasts for about 8 to 12 hours.
2nd stage- Contractions push the baby out of the womb:
the delivery of the baby. This stage of labour lasts usually
for about an hour.
J
IIB!
3rd stage- The contractions cause the placenta to peel
off: delivery of the placenta. This lasts for about 20-30
minutes.
During the intra-natal period it is important to
maintain
• Clean and hygienic delivery conditions - five cleans
that include
- Clean hands
- Clean delivery surface
- Clean cord cut
- Clean cord ties
- Clean cord stump care.
50 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Bi
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• • -
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ANNEXURE 4 - Reading material
on post-natal care (PNC)
....... ............... .................................
WHAT IS PNC?
Post-natal period is the period of six weeks immediately
after delivery, which is important both for the mother
and the newborn. In this period, the changes, which
have taken place in the organs/system during pregnancy
in the woman, come back to normal, except the breasts.
Mother and the newborn are susceptible to some
problems which you should be aware of, so that they
can be guided for treatment/referral. Postpartum care
encompasses management of the mother, newborn, and
infant during the postpartum period.
The time when effective PNC can make the most
difference to the health and life chances of mothers and
newborns is in the early neonatal period, the time just
after the delivery and through the first seven days of life.
However, the whole of the neonatal period, from birth
to the 28 th day after the birth, is a time of increased risk.
Deaths during the first 28 days of babies who were bom
alive is reported by all countries in the world as the
neonatal mortality rate (the number of babies who die in
the first 28 days) per 1,000 live births. Similarly, reports
of maternal mortality include deaths of women from
complications associated with postnatal problems, not
just problems arising during the birth. Both these rates
are important indicators of the effectiveness of postnatal
care.
During the postpartum period the mother is at risk for
such problems as infection, haemorrhage, pregnancy
induced hypertension (PIH), blood clot formation,
the opening up of incisions, breast problems, and
postpartum depression.
Hence it is important for ASHAs/ JHAs to pay frequent
home visits during the PNC to ensure that the newborn
and mother are safe and check if there are any danger
signals.
PRESCRIBED SCHEDULE FOR PNC VISITS
Home visits of ASHA and JHA are scheduled on
• 3rd, 7th and 42nd day for evaluation of mother’s
health
• 14th, 21st and 28th days for the newborn care
If birth occurs at home, the first visit should target
the crucial first 24 hours after birth. In addition to the
routine PNC visits the ASHAs and JHAs needs to do two
/ three extra visits to LBW babies.
Essential routinefor PNCs
• Assessment of mother and newborn
• Identification of danger signs in mother and newborn
• Advice and counselling
• Referral for complications
Assessmentfor all mothers should include checking the
following:
• Bleeding
• Convulsions or loss of consciousness
• Abdominal pain and fever
• Presence of any cyst/ swelling
• Tightness of stomach
• Cracked / inverted nipples
• Pulse, BP, temperature, pallor, breasts, abdomen,
perineum, bleeding/foul smell /infection indicated by
lochia discharge etc.
• Pus in the stitches
• Burning sensation while passing urine
• Anaemia
Assessmentfor all newborn should include checking the
following:
• Loose motions/ fever
• Umbilical cord
• Breastfeeding
• Comfortable breathing
• Weight
• Head protected and kept warm
• Eye movements
• Passing urine and stool
Extra carefor low birth weight babies (LBW) or small
babies and other vulnerable babies
• Identification of small babies / babies who need extra
care.
• Assessment for danger signs and management or
referral as appropriate.
• Extra support for breastfeeding, including expressing
milk and cup feeding, if needed.
• Extra attention to warmth promotion, such as skin-toskin care, or Kangaroo Care.
• Early identification and rapid referral of babies who
52 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
are unable to breastfeed or accept expressed breast
milk.
• Early identification and referral/management of
emergencies for mother and baby.
• Appropriate detection, management, or referrals are
necessary to save mothers and babies in the event of
life-threatening complications.
Danger signsfor die mother
• Excessive bleeding (Post-partum haemorrhage)
• Foul smelling vaginal discharge/ lochia (sign of
sepsis)
• Fever with or without chills
• Severe abdominal pain
• Pus formation
• Excessive tiredness or breathlessness
• Swollen hands, face and legs with severe headaches or
blurred vision
• Painful, engorged breasts (breast abscess) or sore,
cracked, bleeding nipples
• Headache, blurring ofvision
• Convulsions (Eclampsia)
• Difficulty in passing urine (Urinary Tract Infection)
Danger signs for the baby
• Convulsions
• Movement only when stimulated or no movement,
even when stimulated (lethargy)
• Poor breastfeeding
• Fast breathing (more than 60 breaths per minute),
grunting or severe chest in-drawing
• Fever (above 38°C) / Low body temperature (below
35.5OC),
• Very small baby (less than 1500 grams or bom more
than two months early)
• Bleeding
• Difficulty in breathing (chest in-drawing / grunting)
• Blood in stool
• Yellow palms and soles
BIRTH ASPHYXIA
One of the common causes of death among newborns
is birth asphyxia. The foetus inside the mother s womb
gets air from the mother’s blood through the umbilical
cord. Once the baby is out of the womb, it gets air by
breathing. The cry is the first powerful breath. Most
babies are bom with a good cry and start to breathe
vigorously on their own. A few babies do not. Babies
who do not cry or breathe or have a weak cry or breath
need help. This happens when the baby does not
have enough air during the process of delivery and it
suffocates. This affects the baby’s brain and makes it
appear dull at birth. When an asphyxiated baby is bom,
it appears limp and does not cry.
Definition
A baby who has at birth any one of the following
symptoms is asphyxiated:
• No cry
•
•
•
•
Weak cry
No breathing
Gasping
Weak breathing
Consequences of asphyxia
Immediate (at birth):
• Stillbirth
• Drowsiness
• Unable to suckle
• Baby may die within the first few days
Long term:
If the baby survives it may have:
• Mental retardation
• Epilepsy (seizures and fits)
• Spasticity (Difficulty with walking or moving arms
and hands)
Warning ofAsphyxia during labour:
• Prolonged or difficult labour
• Ruptured membranes with little fluid (dry delivery)
• Green or yellow colour thick amniotic fluid
• Prolapsed cord or tight cord around the neck
• Preterm labour (less than 8 months 14 days gestation)
• Breech presentation (or other abnormal presentation)
Addressing birth Asphyxia
If the baby does not cry or breathe or has a weak cry or
breath, immediately dry and wrap the baby. Use a mucus
extractor to clear the secretions in the airways (mouth,
throat and nose) so that the baby can inhale freely. The
cord need not be cut before the mucus extractor is used.
If the mucus extractor does not result in the baby crying
or breathing, start using the bag & mask immediately.
ASHAs are trained to do this.
Mucus extractor
Bag and Mask
Core Concepts of Maternal Neonatal and Child Health 53
NEONATAL SEPSIS
Definition
In newborns the word sepsis’ refers to any serious
infection in the baby, whether in the lungs, brain or
blood.
How big is the problem?
In India, nearly 1 out of every 10 newborns develops
conditions suggestive of sepsis. Sepsis in the first month
is very serious and can cause the baby’s death. Without
treatment many babies with sepsis die. With treatment,
most live and grow up normally.
Causes of neonatal sepsis
• Mother has infection during pregnancy or delivery.
• During delivery, unclean techniques (poor hand
washing, TEA putting hands inside the mother, using
dirty blade and cord ties).
• Cord becomes infected from unclean cutting or
putting dirty things on cord.
• Baby is weak; bom pre term or with low birth weight
(less than 2,000 gms).
• Baby becomes weak from poor feeding practices,
including not giving breast milk early and exclusively.
• Baby comes in contact with an already infected
person: mother, family members, visitors, TBA or
ASHA.
How can sepsis be prevented?
• Good hygiene during and after delivery - frequent
hand washing, clean clothes for the baby, dean blade
during delivery.
• Keeping the baby warm.
• Breast feeding (early initiation and on demand).
• Keeping the umbilical cord clean and dry.
Advice and counselling
This is one of the important components of the PNC
visits. The new mother and her family need guidance
on several subjects, especially because there are number
of misconceptions regarding the food to be given to
the new mother, breastfeeding, and cord care, etc.
More importantly, they need to know about the types
and scheduling of required immunizations, and birth
registration. The advice and counselling should include
information on the following:
• Nutrition for mother
• Hygienic and warm environment (including personal
hygiene for mother)
• Rooming in
• Registration of birth
• Cord care
• Colostrum feeding and exclusive breast feeding
• Immunisation
• Family planning (including spacing)
• Danger signs
• Follow up
General precautions thefamily must take with the
newborn
The newborn is delicate and can easily fall sick if
the family and mother are not careful. Some general
precautions that the family should take are:
• Bathing the baby: Although it is recommended that
the baby should not be bathed until the first seven
days, many families bathe the baby on the first or
second day. For a normal baby, if the family insists,
the baby could be bathed after the second day. But in
the case of LBW baby, you must insist on waiting for
at least seven days. You should explain that bathing
the baby and leaving it wet or exposed may cause
it to get cold and fall sick Thus, it is better to wipe
the baby with a warm wet cloth and dry the baby
immediately.
• People who are sick with cold, cough, fever, skin
infection, diarrhoea, etc. should not hold the baby or
come in close contact with the baby.
• The newborn baby should not be taken to places
where there are other sick children.
• The newborn baby should also not be taken to places
where there are large gatherings of people.
ROLES AND RESPONSIBILITIES OF ASHA
• Advise the woman at least one check-up within two
weeks of delivery.
• Advise the women to visit the JHA for minor
complaints e.g. sore breasts, cracked nipples, foul
smelling discharge, pain in legs etc.
• Assist JHAs in conducting post-natal clinic and
screening women and children with danger signals.
• Advise registration of birth.
• Counselling on exclusive breast-feeding for the
newborn which:
- Helps in better involution of the uterus.
- Can produce lactational amenorrhea and thus act as
natural contraceptive
• Counselling on contraceptive needs (temporary/
permanent) as required and help women/family to
access them
• Ask mother to report if there is:
- Excessive vaginal bleeding
- Loss of consciousness
- Fast or difficult breathing
- Fever
- Severe abdominal pain
KEEPING NEWBORN WARM AND THE
• If the fluid is yellow/green, as soon as the head is seen
(even before delivery of complete baby), clean the
PROBLEM OF HYPOTHERMIA
mouth of the baby with gauze piece.
Why is it important to keep baby warm after delivery?
Babies have difficulty maintaining their temperature at
• As soon as the baby is born, note the time of birth and
start counting time.
birth and in the first day oflife. They come out wet, and
• Observation of baby at birth or within the first 30
lose heat quickly. If they get cold, they use up energy,
seconds and at 5 after birth for movement of limbs,
and can become sick. LBW and pre-term babies are at
breathing and crying. The figure below will enable
greater risk of getting cold.
the assessment of whether the newborn should be
recorded as a live or still birth. All six have to be “No”
When and why do most newborns get cold?
to declare a still birth. Even if one is “yes” the baby
Most newborns lose heat in first minute after delivery.
should be declared as five birth.
They are born wet. If they are left wet and naked, they
• If there is no cry or a weak cry, if there is no breathing
lose a lot of heat to the air. A newborn baby’s skin is very
or weak breathing or gasping, this condition is called
thin and its head is big in size compared to its body. It
Asphyxia. If the baby is asphyxiated (does not breathe
loses heat very quickly from its head. Babies do not have
at birth), and there is no doctor or nurse, you should
the capacity to keep themselves warm. If the newborn
try to help. This skill will be taught to you in Module
baby is not properly dried, wrapped, and its head
7. However, in many such newborns, your efforts may
is not kept covered, it can lose 2 to 4 degree Celsius
not make enough difference and you should not feel
within 10-20 minutes.
bad or blame yourself if the baby does not respond.
• Provide normal care at birth.
Example: If the baby’s temperature was 97.7 degree
- Dry the baby: Immediately after delivery, the
Fahrenheit (36.5 degree Celsius [normal temperature])
newborn should be cleaned with a soft moist cloth
at the time of birth and if there was a loss of 2.7 degree
and then the body and the head wiped dry with a
Fahrenheit because the baby was not properly dried
soft dry cloth. The soft white substance with which
and covered, the body temperature will become 95
the newborn is covered is actually protective and
degree Fahrenheit (35.0 degree Celsius [below normal
should not be rubbed off.
temperature]).
- The baby should be kept close to mother’s chest and
abdomen.
- The baby should be wrapped in several layers of
Convection
Evaporation
clothing/ woollen clothing depending upon the
season.
RaOtatM
"* J5’’*®
- The room should be warm enough for an adult to
1
feel just uncomfortable. The room should be free
from strong wind.
• Weigh the newborn and decide whether the baby is
normal or LBW.
• Determine whether the baby is term or pre-term.
Conduction
• Measure newborn’s temperature.
w.
Steps for you to take “just after” the baby is bom
• Ask the mother about/observe the fluid after the
waters break
54 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Core .
Ith 55
What is the term for a situation when a baby’s
temperaturefalls below normal?
When a baby has a temperature below normal, it suffers
from hypothermia.
What happens to a baby with hypothermia?
A baby who is cold, and has a low temperature
(hypothermia) suffers from:
• Decreased abUity to suckle at the breast, leading to
poor feeding and weakness.
• Increased risk of death, especially in LBW and pre
term babies.
How can you tell ifa baby is hypothermic?
• The early sign is cold feet.
• Then, the body becomes cold.
The best method is to measure the baby’s body tempera
ture. (This skill has already been taught to you)
How to keep newborns warm
• Before delivery, warm up the room (warm enough for
adults).
• Immediately after delivery, dry the baby.
• Put a cap on the baby since a lot of heat could be lost
though its head.
• Place in skin-to-skin contact with mother.
• Cover or put clothes on the baby, wrap it up with
clean cloth, and place it close to its mother.
• Initiate early breastfeeding.
• Bathing for newborns:
- It is best to wait until the second day to bathe the
baby. One should wait seven days in case of LBW
baby.
- If the family insists on bathing the first day, please
ask them to delay for at least six hours to give the
baby time to adjust with its new environment.
- For small and pre-term babies, do not give a bath
until the baby gains weight (this could be few weeks)
and weight of baby become 2,000 gm.
• To keep a small baby clean, you can give a fight oil
massage but making sure that the room is warm
and the baby is not left uncovered for more than 10
minutes. DO NOT pour oil into any orifice, like the
nose or ears at any time.
• Keep baby loosely clothed and wrapped.
• If it is very warm outside, make sure the baby is not
too heavily clothed and wrapped; the baby can also
get too hot.
BREAST FEEDING
Benefits for the baby
• Early skin-to-skin contact keeps the baby warm.
• It helps in early secretion of breast milk.
• Feeding first milk (colostrum) protects the baby from
diseases.
• Helps mother and baby to develop a close and loving
relationship.
BREASTFEEDING OBSERVATION TIPS
Signs of breastfeeding going well
Benefitsfor the mother
• Helps womb to contract and the placenta is expelled
easily.
• Reduce the risk of excessive bleeding after delivery.
Importantfacts about breastfeeding
• Start breastfeeding immediately or at least within one
hour after birth. Give nothing else, not even water.
• Baby should be put to the mother’s breast even before
placenta is delivered. It is useful for both the baby as
well as the mother.
• Breastfeed as often as the baby wants and for as long
as the baby wants. Baby should be breastfed day and
night at least 8-10 times in 24 hours.
• Feeding more often helps in production of more milk.
The more the baby sucks, more milk is produced.
• Baby should not be given any other liquid or foods
such as sugar water, honey, goat’s/cow’s milk and not
even water.
Why only breastfeeding?
Giving other food or fluid may harm the baby in
following ways
• It reduces the amount of breast milk taken by the
baby.
• It may contain germs from water or on feeding bowls
or utensils. These germs can cause diarrhoea.
• It may be too dilute, so the baby becomes
malnourished.
• Baby does not get enough iron from cows and goats
milk and may thus develop anaemia.
• Baby may develop allergies.
• Baby may have difficulty digesting animal milk; the
milk can cause diarrhoea, rashes or other symptoms.
Diarrhoea may become persistent.
• Breast milk provides all the water a baby needs.
Babies do not need extra water, even during the
summer months.
L
-
Mother's body relaxed, comfortable, confident, eye
contact with baby, touching
Refer to FRU/ Dist/ tertiary hospital
Baby's mouth well attached, covering most of the
areola, opened wide, lower lip turned outwards
Mouth not opened wide, not covering areola
Lips around nipple
Suckling well, deep sucks, bursts with pauses
Cheeks round, swallowing heard or seen
Rapid sucks, cheeks tense or sucked in smacking or
clicking sounds
Baby calm and alert at breast, stays attached,
mother may feel uterus cramping, some milk may be
leaking (showing that milk is flowing)
Baby restless or crying, slips off breast; Mother not
feeling cramping, no milk is leaking (showing that
milk is not flowing)
After feed, breast soft, nipples protruding
After feed, breast full or enlarged, nipples may be
red, cracked, flat or inverted
BREASTFEEDING. /
• Breastfeeding postpones mother's menstrual cycle, hence prevents pregnancy.
• Often a baby is breastfed only after the third day. This starves the baby and affects the milk flow.
• Immediate breast feeding within half an hour after birth is vital for the baby. It gives baby nutrition and immunity
against illnesses. It shrinks the mother's womb and reduces bleeding. Milk flow is better with frequent suckling.
• Breast milk is the best food for the baby up to 6 months. No other food, including water, is necessary.
• Mother's breasts get prepared for producing milk during pregnancy. On delivery the breasts are ready to secrete
thick milk called colostrum. The baby should be fed with colostrum as it protects the baby from germ-attacks.
The colostrum should not be thrown away.
• Breast milk provides for all the needs of the baby. It also contains sufficient water for the baby's needs. No need
for feeding water separately. More the baby suckles, the more milk is produced.
• Breastfeeding protects the baby from getting diarrhoea and pneumonia.
• Breastfed babies normally feed every two hours. Well-fed babies sleep quietly for 2-3 hours, and gain weight
normally.
Breastfeeding Positions
y
Underarm Position
56 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
i Signs of possible difficulty
Side-lying Position
Cradle Position
Alternate Underarm Position
Core Concepts of Maternal Neonatal and Child Health 57
MANAGING COMMON BREASTFEEDING
PROBLEMS
Sore nipples
Causes:
• Poor latch-on or positioning at breast
Management:
• Improve attachment and/or position.
• Continue breastfeeding (reduce engorgement if
present).
• Build mothers confidence.
• Advise her to wash breasts once a day with water, no
soap.
• Put a little breast milk on nipples after feeding is
finished (to lubricate the nipple) and air-dry.
• Wear loose clothing.
• If nipples are very red, shiny, flaky, itchy, and their
condition does not get better with above treatment, it
may be fungus infection. Apply gentian violet paint
to nipples after each breastfeed for five days. If the
condition does not improve, refer to a doctor.
Other signs are:
• Baby not satisfied after breastfeed and often cries
• Very frequent breastfeeds
• Very long breastfeeds
• Baby refuses to breastfeed
• Baby has hard, dry or green stools
• No milk comes when mother tries to express
• Breast did not enlarge
• Milk did not come in.
Mothers and families think that in thefollowing
situations, their milk is not enough, but in fact, these
conditions do not affect the breast milk supply:
• Age of mother
• Sexual intercourse
• Return of menstruation
• Disapproval of relatives and neighbours
• Age of baby
• Caesarean section delivery
• Many siblings
• Simple, ordinary diet
Problem of not enough milk
Causes:
• Delayed initiation of breastfeeding; infrequent
feeding; giving fluids other than breast milk; mothers
anxiety, exhaustion, insecurity; inadequate family
support.
Management:
• Decide whether there is enough milk or not:
- Does the baby pass urine six times or more each
day?
- Has the baby gained sufficient weight? (During the
1st week there is usually a small weight loss, after
that a newborn should gain 150-200 gm per week.)
- Is the baby satisfied after feeds?
• Reassure the mother.
• If there is not enough milk, have the baby feed more
often.
• Check breastfeeding process to observe mother
attachment and positioning of the baby.
• Encourage rest. Encourage the mother to drink and
eat more.
Signs that the baby is not getting enough milk
Poor weight gain
• Weight gain of less than 500 grams in a month
• Less than birth weight after two weeks
ANNEXURE5Reading material on child care
As most of the child deaths occur during the first five
years of life, care of children below five years is one of
the most crucial components in the MNCH continuum
of care. The child care intervention has four important
components:
• Monitoring growth and development
• Nutrition interventions
• Prevention and management of childhood illnesses
• Immunization
MONITORING GROWTH AND
DEVELOPMENT:
The terms growth and development though used
interchangeably, many times are two different concepts.
Growth is the increase in size of the body - in height,
weight, mid-arm circumference and other measurable
areas. Development is the gaining of skills in all aspects
of the child’s life such as physical development, social
and emotional development, intellectual development
and communication and speech development
The growth and development are both interlinked.
Growth is the best general index of the health of an
individual child, and regular measurements of growth
permit the early detection of malnutrition, frequently
associated with diarrhoea, and other illnesses/
developmental problems and take remedial action at the
earliest. Monitoring growth and development helps in
screening and diagnosing nutritional, chronic systemic
lacunae and endocrine disease at an early stage and has
the potential for significant impact on mortality. The
remedial actions could include supplementary feeding,
prophylaxis against vitamin A deficiency, control of
nutritional anaemia and referral to medical services etc.
to severely malnourished children.
Monitoring the growth of a child requires taking the
same measurements at regular intervals, approximately
at the same time of the day, and seeing how they change
by plotting it on a growth chart.1 If the child is not
growing properly, it means the child is malnourished, i.e.
under nourished.
Passing small amounts ofconcentrated urine
• Less than six times a day
• Yellow and strong smelling
NUTRITION INTERVENTIONS
Nutrition is required for a child to grow, develop, and
remain active and to reach adulthood without illness.
Nutrients such as carbohydrates, fats, proteins are
required in large amounts (macro nutrients), while some
nutrients e.g. Vitamins, Iron, Calcium, Iodine etc. are
required in minimum amounts (micro nutrients).
Children should be give appropriate nutrition according
to ages below:
0-6 months
During this period they should be given exclusive
breastfeeding by feeding them at least eight times a
day. Mothers should be encouraged to breast-feed on
demand. Bottle-feeding should be discouraged and
anxious mothers should be reassured by informing
them that breast milk is the ideal food for young
infants and it contains all nutrients. Chances of
malnutrition in breast-fed infants are less and
it prevents infection, as it is clean and free from
bacteria. Breastfeeding enhances brain development
Breastfeeding increases mother and child bonding and
helps in better development of the child.
6-12 months
During this period, complementary feeding needs
to start. Home based complementary foods after six
months, given four or five times a day, in addition to
continuing breastfeeding as often as the child wants
is best If the child is not breastfed, it may be given
undiluted milk by a cup and complementary food five
times a day. Food should be mashed and it should
be freshly prepared. Washing hands before feeding is
extremely important.
12 months-two years
Continue breastfeeding for two years or beyond. Give
home based food four-five times a day
Two years onwards
Children should be given home-cooked food five-six
times a day as they eat in small quantities.
1 Refer to Thayi Card to see the growth chart
58 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Core Concepts of Maternal Neonatal and Child Health 59
MICRO NUTRIENTS (VITAMIN A, IRON,
IODINE)
women who do not get enough folic acid are more likely
to have babies with very serious birth defects.
Vitamin ‘A’ Deficiency
Vitamin A is important for normal vision. Vitamin A
deficiency is most common between six months and
three years. It can even cause even blindness, with night
blindness the earliest symptom. The government’s policy
on supplementation of micronutrient Vitamin A is:
• Regular consumption of dark green leafy vegetables
or yellow fruits and vegetables
• Breastfeeding feeding with colostrums
• Oral prophylactic doses:
- One dose of 100,000 IU to infants 6-11 months old
- One dose of 200,000 IU to children 1-5 years old
repeated every six months
• A child must receive a total of 9 oral doses of Vitamin
A by the age of five years old.
The Ministry of Health and Family Welfare has revised
the guidelines on IFA supplementation related to the
National Nutritional Anaemia Prophylaxis programme.
This is the outcome of a long process, initiated with
different consultations on anaemia in adolescent girls. In
2003, the National Consultation on Micronutrients with
the ICMR/MHFW began working with a committee
chaired by the DG of the ICMR. They subsequently
worked with the NRHM and various other groups on
the 11th plan that includes:
• Infants between 6-12 months should also be included
in the programme as there is sufficient evidence that
iron deficiency affects this age also.
• Children between 6 months to 60 months should be
given 20mg elemental iron and 100 mcg folic acid per
day per child as this regimen is considered safe and
effective.
For treatment of Vitamin A deficient cases:
• One dose of 200,000 IU immediately at diagnosis
• Follow-up dose of 200,ooo IU four weeks later
IRON DEFICIENCY ANAEMIA
Iron deficiency is the most common cause of anaemia.
Iron deficiency anaemia occurs when the body doesn’t
have enough iron. Iron is important because it helps a
person get enough oxygen throughout your body. The
body uses iron to make haemoglobin. Haemoglobin is a
part of the red blood cells. Haemoglobin carries oxygen
through your body. If you do not have enough iron, your
body makes fewer and smaller red blood cells. Then your
body has less haemoglobin, and you cannot get enough
oxygen. A person might have low iron levels because
of not getting enough iron in food. This can happen in
people who need a lot of iron, such as small children
and adolescents. Anaemia in children is very common
because of inadequate diet and recurrent infections
and worm infestations. It is also common in pregnant
women and those who have heavy menstrual bleeding.
FOLIC ACID DEFICIENCY ANAEMIA
Folic acid deficiency anaemia happens when your body
does not have enough folic acid. Folic acid is one of
the B vitamins, and it helps the body make new cells,
including new red blood cells. The body needs red
blood cells to carry oxygen. If you don’t have enough red
blood cells, you have anaemia, which can make a person
feel weak and tired. So it’s important that you get enough
folic acid every day. Most people get enough folic acid
in the food they eat. But some people either don’t get
enough in their diet if they don’t eat enough foods that
contain folic acid. These include citrus fruits, leafy green
vegetables, and fortified cereals. Other people have
trouble absorbing it from the foods they eat. Pregnant
National IMNCI guidelines for this supplementation to
be followed.
• For children (6-60 months), ferrous sulphate and
folic add should be provided in a liquid formulation
containing 20 mg elemental iron and lOOmcg folic
add per ml of the liquid formulation. For safety
reason, the liquid formulation should be dispensed in
bottles so designed that only 1 ml cab be dispensed
each time.
• Dispersible tablets have an advantage over liquid
formulations in programmatic conditions. These
have been used effectively in other parts of the world
and in large scale Indian studies. The logistics of
introducing dispersible formulation of Iron and Folic
Acid should be expedited under the programme.
The current programme recommendations for pregnant
and lactating women should be continued.
School children, 6-10 year old, and adolescents, 11-18
year olds, should also be included in the National Nutri
tional Anaemia Prophylaxis Programme (NNAPP).
• School children, 6-10 year old, and adolescents, 11-18
year olds, should also be included in the National
Nutritional Anaemia Prophylaxis Programme
(NNAPP).
• Children 6-10 year old will be provided 30 mg
elemental iron and 250 mcg folic acid per child per
day for 100 days in a year.
• Adolescents, 11-18 years will be suppiemen ted at the
same doses and duration as adults. The adolescent
girls will be given priority.
IODINE DEFICIENCY
Iodine is a very important trace element. It is required
60 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
for the normal growth and development of human
beings. Its deficiency during pregnancy can lead to
spontaneous abortion/still birth and cretinism/mental
retardation in children.
reappears, the child may be given more food than
normal to regain lost weight.
Diarrhoea can be prevented by:
• Exclusively breastfeeding for the first six months.
• Washing hands thoroughly before cooking food and
feeding the child and keeping containers clean for
preparing the food and for feeding the baby.
• Keeping the food and drinking water covered.
• Consuming freshly prepared food within one hour.
• Keeping the house and neighbouring area clean
and proper disposal of waste so that houseflies don’t
breed.
• Constructing sanitary latrines for each household.
Children should be given an iron and protein rich diet
consisting of jaggery, milk, eggs, pulses, green leafy
vegetables, guavas, apples, etc. Children have access to
AWW Services where supplementary food is provided
for the child up to the age of 5. Malnourished children
are to be given additional food supplements.
PREVENTION AND MANAGEMENT OF
CHILDHOOD ILLNESSES:
Major childhood illnesses include diarrhoea and
Acute Respiratory Infection (ARI).
Diarrhoea is marked by liquid or watery stools passed
more than three times in a day. Normally there are three
types of diarrhoea:
• Acute watery diarrhoea which lasts not more than 14
days
• Dysentery is diarrhoea with visible blood in stools
• Persistent diarrhoea begins acutely but is of unusually
long duration i.e. lasting more than 14 days.
Diarrheal diseases are a major cause of death and disease
among children under five years. The majority of the
diarrhoeal deaths are due to dehydration (loss of water
and minerals). Golden rules to observe if a child has
diarrhoea are:
• If the child is breastfed, continue breast-feeding more
frequently.
• If the child has started consuming other foods,
continue feeding small quantities of these items
• Give extra fluids
• Give ORS (Oral Rehydration Solution)
• Refer in case of danger signs
• After the child recovers and normal appetite
Acute Respiratory Infection
Acute Respiratory Infection (ARI) is an important cause
of mortahty and morbidity in children. Most children
up to the age of five years are susceptible to ARI. If not
treated in time, some of children develop pneumonia,
which can result in death. Good nutrition, timely
administration of Vitamin A, and avoiding exposure to
cold, dust and smoke helps in preventing pneumonia.
The child might have ARI if it has some or all of the
following symptoms:
• Cough
• Running nose
• Fever
• Difficulty in breathing
Serious morbidity and death are preventable if it is iden
tified early and treated/referred in time. When a child
has suspected ARI do the following:
• Keep the child warm.
• Give plenty of fluids and continue breast-feeding.
• Give home remedies - ginger, honey, lemon, kadha,
etc.
• Increase feeds after the child recovers.
• Help the child rest
• Access NMCH services and get prompt treatment.
MANAGING MILD CASES OF DIARRHOEA AT HOME: PREPARATION OF ORS
1. Wash your hands
with soap
3. Pour 1 litre of drinking
4. Stir well until the powder
water (boiled and cooled)
is mixed thoroughly
2.2. Pour
Pourall
allthe
theORS
ORS
powder
powderinto
into11 litre
litre
O—
k
A
i
I
__
I
■__________________________________________________________________________
Preparation of home made ORS:
Take one glass (200ml) of water, add a pinch of salt and a spoon of sugar
V
SIX IMPORTANT MESSAGES FOR
PREVENTING CHILD MALNUTRITION
• Exclusive Breastfeeding: Up to the age of six months,
give only breast milk; no water should be added.
• Complementary Feeding: At the age of six months,
add other foods. Breastfeeding alone is not enough,
though it is good to continue breastfeeding for at
least one to two years more. There are five things to
remember about complementary feeding:
- Consistency: Initially the food has to be soft and
mashed. But later, anything that adults eat can be
given to the child, with fewer spices. Do not dilute
food. Keep it as thick as possible, for e.g. ‘give daal
not daal ka pani’.
- Quantity: Gradually increase the amount of such
foods. Till at about one year, the child gets almost
half as much nutrition as the mother.
- Frequency: The amount of complementary foods
given should be equal to about half what the adult
needs in terms of nutrients. But since the child’s
stomach is small, this amount has to be distributed
into four to five, even six feeds per day.
- Density: The food also has to be energy dense, low
in volume, high in energy, therefore, add some oil
or fats to the food. Family could add a spoon of
it to every roti/every meal. Whatever edible oil is
available in the house is sufficient.
- Variety: Add protective foods - green leafy
vegetables. The rule is that the greener it is, or the
redder it is, the more its protective quality. Similarly
meat, eggs, fish are liked by children and very
nutritive and protective.
• Feeding during the illness: Give as much as the child
will eat; do not reduce the quantity of food. After the
illness, to catch up with growth, add an extra-feed.
Recurrent illness is a major cause of malnutrition
• Prevent illness: Recurrent illness is a major cause
of malnutrition. There are six important things to
remember which could prevent illness:
- Hand washing: before feeding the child, before
preparing the child’s food, and after cleaning up the
child who has passed stools. This is the single most
useful measure to prevent recurrent diarrhoea.
- Drinking water to be boiled. Though useful for
everyone, it is of particular importance to the
malnourished child with recurrent diarrhoea.
- Full immunization of the child: Tuberculosis,
diphtheria, pertussis and measles are all prevented
by immunization and are the diseases that cause
severe malnutrition. In malnourished children, these
diseases are more common and life threatening,
than in normal children.
- Vitamin A: To be given along with measles vaccine
in the ninth month and then repeated once every
six months till five years of age. This too reduces
infections and night blindness, all of which is more
common in malnourished children.
- Avoid persons with infections, especially with a
cough and cold picking up the child, and handling
the child, or even coming near the child during the
illness. This does not apply to mother, but even she
should be more rigorous in handwashing and more
careful in handling the baby.
- Preventing Malaria: In districts with malaria the
baby should sleep under an insecticide treated bed
net. Malaria too is a major cause of malnutrition.
• Access to health services
- Seek prompt MNCH services. On the very first
day of the illness, if you help the mother decide on
whether it is a minor illness for which home remedy
would be adequate, or to be referred to a doctor,
such a decision could save fives. Early treatment
would prevent malnutrition.
- Access to contraceptive services is important. If the
age of mother is less than 19, or the gap between
two children is less than three years, there is a much
higher chance of the children being malnourished
• Access to AWW services that include:
- Food supplement for the child up to the age of 5.
This could be a cooked meal, or in the form of take home rations. Malnourished children are to be given
additional food supplements. For children below
the age of two, take - home rations are to be given.
Pregnant women and lactating mothers up to six
months are entitled to get food supplements.
- Weighing the baby and informing the family of the
level of malnutrition.
- Conducting Village Health and Nutrition Day
(VHND) activities. The JHA visits every month
and the child is immunized, given Vitamin A
supplements, paediatric iron supplements. Oral
Rehydration Salts (ORS) packets or drugs as needed
for illness management.
ANAEMIA IN CHILDREN UNDER FIVE YEARS
OF AGE
Anaemia is important to diagnose because it commonly
comes along with malnutrition. It may be a cause of
poor appetite. Blood testing is essential, but even in its
absence based on observation of pallor alone, treatment
can be started.
Unusual paleness (pallor) of the skin of the soles or
palms is a sign of anaemia. To see if the child has
anaemia, look at the skin of the child’s palm Children
62 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
between 6 months to 60 months should be given 20mg
elemental iron and 100 mcg folic acid per day per child
as this regimen is considered safe and effective.
. Hold the child’s palm open by grasping it gently from
side to side. Do not stretch the fingers backward. This
may cause pallor. Compare the child’s palm with your
own palm and the palm of other children. If the skin is
paler than of others, the child has pallor.
unconscious child does not waken at all. This child does
not respond to touch, loud noise or pain.
Step 5: Ensure that the child is referred to a PHC/CHC
immediately.
Treatment for anaemia in children between 6 months to
60 months should be 20mg elemental iron and 100 mcg
folic acid per day. For a child 2 years and above, also give
one tablet of Albendazole for deworming once every six
months. For a child less than two years, give half a tablet
of Albendazole (Refer to Annexure 6). Iron rich foods
are needed for the young child. If anaemia does not
improve, the child must be referred to a doctor for more
complete blood tests and treatment
HOW TO ASSESS A SICK CHILD FOR
DANGER SIGNS?
Step 1: ASK: Is the child able to drink or breastfeed?
A child has the sign “not able to drink or breastfeed” if
the child is not able to suck or swallow when offered a
drink or breast milk. If the mother says that the child is
not able to drink or breastfeed, ask her to describe what
happens when she offers the child something to drink.
For example, is the child able to take fluid into his mouth
and swallow it? If you are not sure about the mother’s
answer, ask her to offer the child a drink of clean water
or breast milk. Look to see if the child is swallowing the
water or breast milk. A child who is breastfed may have
difficulty sucking when his nose is blocked. If the child’s
nose is blocked, clear it If the child can breastfeed after
his nose is cleared, the child does not have the danger
sign.
Step 2: ASK: Does the child vomit everything?
A child who is not able to hold anything down at all has
the sign “vomits everything.” What goes down comes
back up. A child who vomits everything will not be able
to hold down food, fluids or oral drugs. A child who
vomits several times, but can hold down some fluids,
does not have this general danger sign.
Step 3: ASK: Has the child had convulsions?
Ask the mother questions on whether the child has
suffered from convulsions (local term) or not
Step 4: LOOK: See ifthe child is lethargic or
unconscious.
The lethargic child is sleepy when the child should be
awake. A child who stares blankly and does not appear
to notice what is happening around is also lethargic. The
NATIONAL IMMUNIZATION SCHEDULE
Immunization is one of the most well-known and cost
effective methods of preventing diseases.
Many serious germ diseases in children can be prevented
by immunization. These vaccines are given free to all
children by the JHA and at the sub-centers and the PHC.
Some vaccines need cold storage during transportation
to retain their power. Although most of the Vaccine
Preventable Diseases (VPDs) are now under controll,
immunization has to be sustained, not only to prevent
VPDs, but also to:
• Eliminate Tetanus,
• Reduce the incidence of Measles and
• Eradicate Poliomyelitis.
The six vaccine preventable diseases are
• Poliomyelitis (can be prevented by OPV)
• Tetanus (can be prevented by DPT)
• Diphtheria (can be prevented by DPT)
• Pertussis (whooping cough) (can be prevented by
DPT)
• Measles (can be prevented by measles vaccine)
• Childhood tuberculosis / lung TB (can be prevented
by BCG)
The vaccines must be given at the right age, right dose,
right interval and the full course must be completed to
ensure the best possible protection to the child against
these diseases. The schedule that tells us when and how
many doses of each vaccine are to be given is called
immunization schedule.
Core Concepts of Maternal Neonatal and Child Health 63
NATIONAL IMMUNIZATION SCHEDULE (NIS) FOR INFANTS, CHILDREN AND PREGNANT WOMEN
Vaccine
j When to give
Dose
Route
Site
S -: ■
For Pregnant Women
TT-1
Early in pregnancy
0.5 ml
Intra-muscular
Upper Arm
Upper Arm
Upper Arm
TT-2
4 weeks after TT-1 *
0.5 ml
Intra-muscular
TT- Booster
If received 2 TT doses in a
pregnancy within the last 3 yrs*
0.5 ml
Intra-muscular
BCG
At birth or as early as possible
till one year of age
0.1ml (0.05ml until
1 month age
Intra-dermal
Left Upper Arm
Hepatitis B
At birth or as early as possible
within 24 hours
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh
OPV-O
At birth or as early as possible
within the first 15 days
2 drops
Oral
Oral
OPV1.2&3
At 6 weeks, 10 weeks & 14 weeks
2 drops
Oral
DPT1.2&3
At 6 weeks, 10 weeks & 14 weeks
0.5 mi
Intra-muscular
it
I>
a
For Infants
Oral
Antero-lateral side
of mid-thigh
Antero-lateral side
of mid-thigh
Hepatitis B 1, 2
& 3****
At 6 weeks, 10 weeks & 14 weeks
Measles
9 completed months-12 months,
(give up to 5 years if not received
at 9-12 months age)
0.5 ml
Sub-cutaneous
Right Upper
Arm
Vitamin A
(Istdose)
At 9 months with measles
1 ml
(1 lakh IU)
Oral
Oral
0.5 ml
Intra-muscular
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DPT booster
16-24 months
0.5 ml
Intra-muscular
Antero-lateral side
of mid-thigh_____
OPV Booster
16-24 months
2 drops
Oral
Oral
Japanese
Encephalitis**
16-24 months with DPT/OPV
booster
0.5 ml
Sub-cutaneous
Left Upper Arm
Vitamin A***
(2nd to 9th
dose)
16 months with DPT/OPV booster
Then, one dose every 6 months
up to the age of 5 years.
2 ml
(2 lakh IU)
Oral
Oral
DT Booster
5-6 years
0.5 ml
Intra-muscular
Upper Arm
TT
10 years & 16 years
0.5 ml
Intra-muscular
Upper Arm
‘Give TT-2 or Booster doses before 36 weeks of pregnancy.
However, give these even if more than 36 weeks have
passed. Give TT to a woman in labour, if she has not
previously received TT
** SA 14-14-2 Vaccine, in select endemic districts after the
campaign.
*** The 2nd to 9th doses of Vitamin A can be administered
to children 1-5 years old during biannual rounds, in
collaboration with ICDS.
**** In select states, districts and cities.
Proposed Changes in the National Immunization
Schedule: 2009-10
• DT Booster to be replaced by DPT Booster at 5-6
years of age.
• In select well-performing states, MR to be given with
DPT Booster at 16-24 months (Dose: 0.5 ml; Route:
Sub-cutaneous; Site: Right Upper Arm)
• DPT and HepB vaccines at 6,10 and 14 weeks to be
replaced by DPT-HepB-Hib (Pentavalent) vaccine.
64 Community Level interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
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Core Concepts of Maternal Neonatal and Child Health 65
ANNEXURE6Post-exam for Module 1 *
* Facilitator will need to update all questions that relate to population/census data or
statistical measures for a given time period.
8. What will be the percentage of HB in cases of acute blood deficiency?
a. <10%
b. <7%
9. During pregnancy, in which trimester do the weeks 12-28 appear?
a. 1
b. 2
c. 3
10. When does ANC begin?
a. 3 months
b. 5 months
c. Immediately after sexual intercourse (As soon as the pregnancy is suspected)
Name:
Place:
Date:
PHC name:
11. How many times do mothers usually visit the health centre after registering for ANC?
a. 3
b. 4
c. 5
12. What is the normal BP for a human being?
a. 110/80
b. 120/80
1. Based on current census data, what is the worldwide annual infant mortality rate (IMR) for children
below the age of 5 years?
a. 1 million
b. 5 million
c. 10 million
2. Based on current census data, what is the worldwide mortality rate of women who are pregnant and
mortality rates of women due to complications during child birth and post natal complications?
a. 5 lacs
b. 5.3 lacs
c. 4 lacs
3. How is MMR (maternal mortality rate) measured?
a. No. of deaths per 100 pregnant women
b. No. of deaths per 100000 pregnant women
c. No. of deaths per 1000 pregnant women
4. What is the IMR (Infant mortality rate) according to current census data?
a. 60/1000 live births
b. 50/1000 live births
c. 40/1000 live births
5. This is one of the most important reasons for the mortality of a mother. Choose the correct one from
the below mentioned options
a. Excessive Bleeding
b. Malaria
c. Typhoid
13. How many doses of TT injection should be administered to a first time pregnant woman (Primi)?
a. 2
b. 3
c. 4
14. What symptoms can be pinpointed from a urine protein test?
a. Blood deficiency
b. Pre eclampsia (high BP)
c. Heart condition
15. Which among the below mentioned options is the best permanent family planning option?
a. Mala.D
b. Condom
c. Tubectomy
16. At the facility level, in which level do 24/7 PHC and non. FRU CHC appear?
a. 1st level
b. 2nd level
c. 3rd level
17. For a woman who is in her first pregnancy, what height of this woman will indicate that she will have a risky
pregnancy?
a. 140 centimeters
b. 160 centimeters
c. 170 centimeters
6. Who is called a newborn baby? Choose the answer from the below mentioned options
a. 0 — 25 days of birth (actually 0-28 days)
b. 0 — 6 months of birth
c. 0 — 1 year of birth
18. How many iron supplement tablets are given to a pregnant woman as a precaution to guard against blood
deficiency?
a. 100
b. 200
c. 300
7. In how many districts of Karnataka has the Sukshema program been implemented?
a. 6
b. 8
c. 10
19. For a pregnant woman what is the time line for a full term pregnancy?
a. 32 - 36 weeks
b. 37 - 42 weeks
c. 42 - 45 weeks
66 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Core Concepts of Maternal Neonatal and Child Health 67
20. What is the duration of post natal care?
a. 42
b. 40
21. In which trimester of the pregnancy will a still birth occur?
a. After 28 weeks
b. After 20 weeks
22. What is intra partum care?
a. Pre natal care
b. Post natal care
c. Care during child delivery
23. Most mother mortality cases happen during the below mentioned instances?
a. PNC
b. INC
c. ANC
32. Whose information does the mother card contain?
a. Mother
b. Child
c. Pregnant woman
d. All of the above
33. Who enters details into the mother card?
a. JHA and RP
b. RP and doctor
c. ASHA and JHA
d. JHA and doctor
34. Who is the target audience for FFC?
a. Neighbours
b. Pregnant woman
c. Family members
35. How many important communication topics make up the FFC?
24. How many stages are there in a pregnancy?
a. 3
b. 4
25. For a first time pregnancy, what is the duration of the first stage of child birth?
a. 0- 12 hours
b. 0 — 15 hours
26. How many times must a newborn baby be breast fed in a day?
a. 8- 10 times
b. 3-4times
27. The below mentioned options are the reasons for infant mortality - Tick the correct options
a. Diarrhea
b. ARI (Acute Respiratory Infection)
c. Measles
d. Typhoid
e. malaria
f. HIV/AIDS
28. How many times is DPT prescribed?
a. 5 times
b. 3 times
29. Which disease does BCG control?
a. Tuberculosis (TB)
c. Throat inflammation
30. At which stage is ETT implemented?
a. At the village level
b. At the sub centre level
c. At the PHC level
d. At the district level
a. 12
b. 7
c. 8
36. Who enters information into the HBMNC (Home Based Maternal & Newborn Care) tool?
a. JHA and RP
b. RP and doctor
c. ASHA
d. JHA and doctor
37. What is ARS?
a. Health safe guard committee
b. Health safe guard organization
c. Health safe guard armour
38. What is the main aim of community monitoring?
a. Guarantee services due to the community
b. Guarantee that the pregnant woman's family is accessing all health related services
c. All of the above
39. Which among the below mentioned options is a mid media activity?
a. Home visit
b. Street play
c. Counselling
d. All of the above
40. Which among the below mentioned options is the primary responsibility of an RP?
a. Entering information into the mother card
b. Support for ASHA workers
c. Home visits
d. All of the above
31. We can reach the below mentioned sections through hl I?
a. Those living below the poverty line
b. Dalits
c. Migrants
d. Ail of the above
68 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Core Concepts of Maternal Neonatal and Child Health 69
proving Maternal, Neonatal
,1th: A Training Tool Kit
iaCnira
'
___ .
11A M-V*2 T* > n
tn.
SUKSHEMA'S
COMMUNITY LEVEL ,
■ IN^TEFIV ENTI0N$
.■
Community Level Interventions >
for Improving Maternal, Neonatal
and Child Health Training Tool
Kit: Sukshema's Community Level
Interventions is the third module of
the tool kit in a series of seven on
enhancing community engagement for
improving outreach, shaping demand
and strengthening accpuntabdity to
improve maternal, neonatal and child
health outcomes in Karnataka.
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
<4
J
SUKSHEMA'S
COMMUNITY LEVEL
INTERVENTIONS
ACKNOWLEDGEMENTS
The following institutions and individuals contributed to
the idea, design, writing and editing of this tool kit:
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
Mr. Mohan HL, UOM
Dr. Krishnamurthy, UOM
Ms. Mallika Biddappa, KHPT
Ms. Prathibha Rai, KHPT
Ms. Navya R, KHPT
Mr. Somashekar Hawaldar, KHPT
Dr. Suresh Chitrapu, KHPT
Mr. Balasubramanya KV, KHPT
Dr. Troy Cunnigham, KHPT
Mr. Arin Kar, KHPT
Mr. Ajay Gaikwad, KHPT
Mr. Nagaraj R, KHPT
Mr. Manjunath Dodawad, KHPT
Dr. B M Ramesh, KHPT
Dr. Krishnamurthy, KHPT
Dr. James Blanchard, UoM
Ms. Lakshmi C, KHPT
Ms. Sharada HR, KHPT
THE EDITORIAL TEAM:
Mr. H.L. Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Ms. Dorothy L. Southern, KHPT Consultant
The photographs are by KV Balasubramanya.
They have been used in the module with consent
from the community.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & Sth Floor
#1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91-8040400200
Fax:91-80-40400300
www.khpt.org
Year of Publication: 2014
Copyright: KHPT
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
^■Fsukshema
Improved Maternal, Newborn & Child Health
off!
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The Community Level Interventions for Improving Maternal, Neonatal and
Child Health Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 3: Sukshema's Community Level Interventions is aimed at Resource
Persons (RPs) to provide an overview of the community level interventions
planned under the Sukshema project. Enhancing communication is highlighted
in the family focused communication intervention and the enumeration and
tracking intervention seeks to bridge the gaps that occur in the Maternal
Neonatal and Child Health (MNCH) continuum of care. Two other tools are
introduced: one to improve the quality of interaction during home based care,
the Home Based Maternal Newborn Care (HBMNC) Tool; and the other to
enhance planning, accountability and monitoring of health service delivery
through the Supportive Community Monitoring (SCM) Tool. This module also
gives participants the opportunity to clarity roles and responsibilities of a
number of field level workers in the Sukshema project and in the Government
of Karnataka (GoK) health service.
4
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
ACRONYMS
6
Getting Started: The Doorway to Successful Training
7
SESSIONS
Session 1: Understanding Sukshema's community level interventions
8
Session 2: Enhancing communication and coordination using family focused communication
9
Session 3: The Arogya Mantap - providing space for collaboration and discussion
11
Session 4: Bridging gaps in MNCH continuum of care through enumeration and tracking
12
Session 5: Improving the quality of interaction in providing home based maternal,
neonatal and child care
14
Session 6: Enhancing accountability through supportive community monitoring
15
Session 7: Staff structure, roles and responsibilities and drawing-up an action plan
17
Session 8: Training evaluation and feedback
20
ANNEXURES
Annexure 1: Reading material on Village Health Sanitation Nutrition Committees (VHSNC)
22
Annexure 2: Reading material on Government infrastructure related healthcare
24
Annexure 3: Reading material on Government schemes for mothers and children.
25
Annexure 4: Checklists for Sukshema's project field staff
28
Sukshema's Community Level Interventions
5
ANC
ARI
ARS
ASHA
AWW
BCC
BPL
CBO
CDL
DOH
EDD
ETT
FLW
FP
FRU
GoK
HBMNC
IEC
IMR
IPC
JHA
JSY
JHA
KHPT
MDG
MMR
MNCH
NGO
NRHM
PHC
PNC
PRI
RP
SBA
SC
SC/ST
SCM
SHRC
SHS
SRS
TBA
TT
VHW
VHSNC
6
Ante Natal Care
Acute Respiratory Infection
Arogya Raksha Samitis
Accredited Social Health Activist
Anganwadi Worker
Behaviour Change Communication
Below Poverty Line
Community Based Organization
Community Demand List (CDL1) Tool
Department of Health
Expected Date of Delivery
Enumeration and Tracking Tool (El 11)
Frontline Health Worker
Family Planning
First Referral Unit
Government of Karnataka
Home Based Maternal Newborn Care
Information, Education, Communication
Infant Mortality Rate
Inter Personal Communication
Junior Female Health Assistant
Janani Suraksha Yojana
Junior Female Health Assistant
Karnataka Health Promotion Trust
UN Millennium Development Goals
Maternal Mortality Rate
Maternal, Newborn and Child Health
Non-Government Organization
National Rural Health Mission
Primary Health Centre
Post-natal Care
Panchayat Raj Institution
Resource Person
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Supportive Community Monitoring
State Health Resource Centre
State Health Society
Sample Registration System
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health Worker
Village Health and Sanitation Nutrition Committee
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
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SESSION 1:
UNDERSTANDING
SUKSHEMA'S
COMMUNITY
INTERVENTIONS
J
Process
Objective
• To help the participants understand the Sukshema
project's MNCH interventions package as a whole.
• The drdes of influence
& Methodology
Discussion and group work
e
• Tell the participants that woman and child’s health is
determined by various factors beyond just medical
factors.
• Start at the inner circle and explain that many
external forces determine a womans health making
decisions or her ability to make those decisions.
• Working with all these different circles of influence is
important to support both mothers and children.
• Divide the participants into five groups.
• Assign each group a ‘circle’ in the Circle of Influence
and ask them to discuss what they could do to get
support for mother and child access to MNCH
continuum of care services.
• Allow 15 minutes for discussion. Ask a representative
from each group to take 5 minutes to share their main
discussion points.
• Ask other groups to share any other key information.
• Introduce the Sukshema proj ect’s MN CH
interventions. These focus on the first three ‘circles’:
the family, the FLWs and Community Structures:
Duration
1 hour
Training Materials
Markers and brown sheets/ chart paper
Tips for facilitators
The circle of influence starts with family members induding
mother, father, husband, mother-in-law, father-in-law,
grandmother, etc., but extends much further than the
family. It reaches to the village elders, such as caste leaders,
sanghas, Panchayat members, and then to community
structures, such as the PHC and SC. Participants will need
help to understand the extent of these influences on a
woman's health making decisions. They will also need to
see the link between the interventions as a whole, although
they will be implemented separately in the Sukshema
project's MNCH intervention.
1.1 CIRCLES OF INFLUENCE
• Ask the participants, “Who has the most influence
on a womans health making decisions?’
• Encourage them to come up with ideas. Ask
probing questions until you get some responses.
• Note their responses on a flip chart
• Ask if other people, groups and institutions also
have an influence on womans health making
decisions?
• Probe further and ask who are the main
influencers at the village level are.
• Tell them that in addition to all the influences they
have listed, there are also larger influences such as
religious leaders, media, political leaders/ policy
makers and customs and traditions.
• Tell them that all these people/institutions at
different levels have the power to influence MNCH
related opinions and decisions both positively or
negatively.
• Display the ‘Circle of Influence’ diagram at the
front of the training room.
'■i .
■
‘
-
............ ...
..
ASHA. AWW, JHA
Methodology
Grandmother, husband,
mother, mother-m-law..
lather!
■ __
8
Community Level interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
.
Role play, group work
and discussion
Training Materials
I
Markers and brown sheets/ card sheets
..
;
.
Tips for facilitators
• To help the participants understand the concept and
importance of family focused communication
• To understand how gender and family influence the
behaviour of pregnant women
VHSC, ARS. PRI.
Village heads
r . ‘ r .;•?
5
8s
SESSION 2:
ENHANCING COMMUNICATION
AND COORDINATION USING FAMILY '
FOCUSED COMMUNICATION
/J
- -
O Objective
klede..Government.
Pninir*:
Poitucs
- Family focused communication - to address the
family ‘circle’.
- Enumeration and tracking using the Community
Demand List (CDL) Tool - to address the FLWs
‘circle’.
- Home Based Maternal Neonatal Care (HBMNC)
Tool - to address the FLWs ‘circle’.
- Supportive Community Monitoring (SCM) Tool - to
address the community structure circle’.
- Arogya Mantap - to address all three ‘circles’.
• Consohdate the main points of Session 1:
- The focus of the community interventions is to build
the skill of the FLWs and help them work better
with the mothers, children and their famflies. The
tools will enhance the skills, guide and improve the
quality of work of the FLWs, which in turn will help
enhance MNCH outcomes.
• Tell the participants that in the following sessions
they will learn more about each of these interventions
and how they are linked.
a
Duration
2 hours
This session highlights the family focused communication
(FFC) intervention. It will help FLWs understand that the
family is a very crucial component of gaining access to
the MNCH continuum of care and to help them improve
their communication skills. FLWs must understand why
conveying MNCH messages to the pregnant woman alone
will not be enough, but that they must involve key family
members for the intervention to successful. They must
also understand the concept of gender and how gender
norms can influence a pregnant woman's health making
dedsions. For the role play, the fadlitator could develop a
script for each actor and give it to the volunteers ahead of
the session so they could practice before performing.
Sukshema's Community Level Interventions
9
Process
2.1 FFC COMMUNICATION
• Ask 6 participants to volunteer to act out the
following role play. Tell them to make their own
dialogues and develop the role play using their own
experiences from the field.
A woman is 8 months pregnant. The ASHA visits her
house to tell her about the importance of institutional
delivery and about birth preparedness. When the
ASHA reaches her home, the mother-in-law refuses
to let her in and tells a lie that the woman is sleeping.
The ASHA takes the JHA along with her the next
day to meet the same woman. This time the pregnant
woman opens the door and looks scared and uneasy
at the ASHA and JFA. They tell her about institutional
delivery and birth preparedness. The woman refuses
and says she is not interested and that she will deliver
at home. The FLWs try to convince her. They ask
her why is she not interested. After much probing
the woman confesses that her grandmother is very
against institutional delivery. The ASHA and JFA
don't know what to do. They go back and discuss
together. They decide to talk to the grandmother alone
the next day. After much opposition, the grandmother
agrees to hear them. They try to explain about the
advantages of institutional delivery. After they finish,
the grandmother tells that she has given birth to 10
children in her house and she doesn’t need to be told
anything. She asks the ASHA and JFA to leave without
paying heed to their words.
• Ask the volunteers to present the role play for all other
participants to watch and listen carefully.
• After the role play ask the following questions and
discuss:
- What happened in the role play?
- What stopped the woman from making her own
independent decision?
- Who influenced her decisions?
- Was the communication by the FLWs proper?
- Did it result in making the right decision in favour
of the woman?
- Did it address the woman alone or the family?
- What could have been done to make the
communication more effective?
- What can we learn from this role play that can be
used in our intervention?
• Ask all the participants to share similar experiences
that they know of in their families or in the course of
their field work
• Consolidate the role play and discussion:
- A woman is not empowered to make her own
decisions in our current rural context because of
power issues.
- A female is taught to be subjected to the decisions of
elders in the family.
- Decision makers are usually the men and the other
powerful figures of the family.
- Therefore, working only with the woman in isolation
will not achieve access to the MNCH continuum of
care services.
- Communication with the entire family is key for
behaviour change
• Divide the participants into three groups and give
each of them one of the following situations:
1. The husband ofa family living below the poverty
line (BPL) is refusing to let his wife go forfamily
planning. She is pregnant with her fourth child
and has three daughters. What will your commu
nication message be, for whom and using which
method?
2. The mother is not allowing her pregnant daughter
to take iron andfolic acid pills forfear that baby
will become dark. The mother is illiterate. What
will your communication message be, for whom
and using which method?
3. The woman does not want to breastfeed the baby
because her mother-in-law has warned her that if
she does then the baby will be cursed. What will
your communication message be, for whom and
using which method?
• Allow 15 minutes to discuss and develop a
communication message. Ask a representative from
each group to take 5 minutes to share their message.
• Ask other groups to comment.
• Tell the participants that the FLWs need the skills
to assess the situation, know whom to focus on,
design an appropriate communication message, and
communicate it effectively with a positive impact.
• The FFC intervention will train FLWs to
communicate effectively using appropriate tools
such as flipcharts, picture cards and other innovative
methods.
2.2 FFC COORDINATION
• Ask the participants who the three key groups of
FLWs are:
• Display a flip chart divided into three columns at the
front of the training room.
• Note their responses in the first column of the flip
chart.
• Ask them to define the duties of each of these groups:
the ASHAs, the JFAs and the AWWs.
• Note their responses in the second column of the flip
chart
• Ask them how these three groups coordinate their
10 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
the quahty of service delivery in the field.
• Consolidate the main focus areas of the FFC:
- Family
- Communication
- Coordination between front line workers
• Details on the FFC intervention will be
further explained in Module 4 of the Tool Kit,
‘Communication and Collaborative Skills for Front
Line Health Workers’.
work in the field.
• Note their responses in the third column of the flip
chart.
• Ask them to share their perceptions and experiences,
both positive and negative, on the nature of
coordination between the three FLWs.
• Tell them that the FFC encourages the three FLWS to
work together to achieve the same objective. Avoiding
duplication and enabling data sharing can improve
KF- ■
i
kJ..
MMBM
SESSION
dtooiuH j3::
aw
THE AROGYA MANTAP-PROVIDING SPACE B
FOR COLLABORATION AND DISCUSSIONS
Objective
:
• To let participants know about Arogya Mantap's role and
activities in providing a collaborative forum for FLWs
s
Methodology
Brainstorming and discussion
•
J
i^^l Duration
30 minutes
I
Training Materials
Markers and brown sheets/ card sheets
Tips for facilitators
Process
;
The Arogya Mantap is an activity of the Sukshema project
to build a collaborative forum at the SC level. It offers space
for all the FLWs and the VHSNC members to come together i
to discuss common issues and generate solutions. Engage
I
the participants in brainstorming and discussions so that
they will understand the concept of the Arogya Mantap, the ■
need for this platform, and its importance.
i
•
;
:
:
• Ask the FEW participants (ASHAs, JHAs or
AWWs) to imagine they are working in a SC area.
• Ask them to think of one important thing they
wish they had to work better and be more effective.
For example, for a teacher might say, I wish I had
the support of parents to ensure that all children
come to school.
• Note their responses on a flip chart.
• Tell the group that in the field they need a space or
a platform where they can meet together to share
and discuss their work, as well as their personal
lives so they can understand each others issues
and concerns.
• Tell them that in order to fill this gap, a forum
called the Arogya Mantap has been developed
where all the ASHAs, JHAs and AWWs, as well as
VHSNC members in each of the SCs where there
is an Arogya Mantap, can meet once a month.
They can discuss the challenges they face in their
work as well as enjoy a time of fellowship, perhaps
planning entertainment activities.
• Meeting regularly in this forum will help them
stay motivated and connected so they can function
more effectively as a group.
Sukshema's Community Level Interventions 11
SESSIONS
BRIDGING GAPS IN THE MNCH CONTINUUM OF
CARE THROUGH ENUMERATION AND TRACKING
Objective
• To help participants understand the usefulness and
importance of enumeration and tracking using the
Community Demand List (CDL) Tool in outreach work
e
Training Materials
Copy of case studies, markers and brown sheets/
chart paper
Tips for facilitators
Methodology
Case study, small group
discussion, plenary presentation
and discussion
Duration
This session does not deal with the details of the
Community Demand List (CDL) Tool, but helps the
participants understand the concept of why the tool was
developed and how it will help the ASHAs in the field
to help all women access the MNCH continuum of care
services.
1 hour and
30 minutes
Process
• Give one of the case studies to each of the five groups.
Casel:
Case 3:
The population ofHerur village of Gangavati Taluk is
around 1000, including 15 pregnant women. Nine of them
work under a contractor. The contractor took these nine
pregnant women to Rampura village for 15 days for some
work. Five out of them are due for thefirst dose of Tetanus
Toxoid (TT) injection andfour of them are duefor a
booster dose of TT. In tins situation, Aw should ASHA
from Herur village ensure that all the pregnant women
receive the TT injections as per the schedule?
There are a total of 10 pregnant women in Bennur village,
Four of them are duefor delivery this month. While two
of thesefour have registered in private hospitals, the other
two have registered in the government hospital. All four
have gone to hospital without any birth preparedness.
What can the ASHA do to ensure they receive PNC
services?
Case 2:
A group offive to six migrant families returned to
Mallapurfrom Mangalore. Three pregnant women are
part of this group. One of them is in the first trimester and
the other two are in the third trimester. One of them has
a 10 year old child. None of these women are registered.
What can the ASHA do to ensure that these three women
receive the care that needs to be given at this period?
Case 4:
'Ihe findings of a survey conducted in Alvandi village on
immunization found that out of the 16 children who had
completed theirfirst year, only 10 had received a complete
package of immunizations. How will the ASHA ensure
that all the children from Alvandi village are completely
immunized?
CaseS:
In Mahalingpura village 10 women have recently
delivered. How will ASHA ensure that all ofthem get
complete PNC services?
12 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• Ask group members to read the case study in the
group, discuss and answer the question in each case
study.
• Allow 15 minutes for discussion, then ask a
representative from each group to take 5 minutes to
read out their case study and share their responses to
the case study’s question.
• Ask other groups to share any other key information
about the case study.
• Continue with the next 4 case studies in the same
manner.
• Highlight that the ASHA is the main point of
reference and link between women and the service
providing facility.
• Ask the participants if a village had 1000 people with
an ASHA in place and there were 25 pregnant women
would all the pregnant women receive all MNCH
services in the continuum of care?
• Note their responses on a flip chart.
• Ask them to share and discuss from their own
experiences of working in the field.
• Consolidate the discussion by pointing out
- Pregnancy and delivery are very normal events.
- Most of the women deliver normally without any
problems, but other women and newborns are at
risk for morbidity and mortahty because they don’t
know about or have access to all MNCH services in
the continuum of care.
- If a pregnant woman misses even one service in
the MNCH continuum of care, the continuum is
broken.
- Many times ANC registration is done so late that
more than 50 % of MNCH services are not provided.
- It is crucial that 100 % of ANC registration is done
and continuum of care is given to all pregnant
women without any gap.
- Every woman needs information about services and
access to ALL services on time and that the ASHA is
responsible for this.
• Tell the participants that the following gaps have been
noted in the field:
- Some of the ASHAs don’t recognize the importance
of the “MNCH continuum of care” concept.
- Some are unaware of all the MNCH continuum of
care services and the timing of the services.
- Some have no effective tools to support them in
their outreach. Though they have many registers
they do not have a means of identifying where the
gaps exist and following up all the women in their
area.
• Ask participants what the solution could be to fill in
the gaps in the continuum of care?
• Note their responses on a flip chart.
• Ask them to share and discuss from their own
experiences of working in the field.
• Consolidate the discussion:
- ASHAs should be supported to build their capacity
in knowing about the MNCH continuum of care
services
- ASHAs should be provided with tools that can help
them plan their outreach in her area to ensure 100
% registration and 100 % continuity in MNCH care
services to avoid any gaps.
• Tell the participants that the Community Demand
List (CDL) Tool has been developed to plan and
monitor their outreach. The tool:
- Provides an overall picture of all women in a specific
area to allow the ASHAs to enumerate and track
them.
- Shows who should be given what services and when
the next service is due.
- Maintains a record that shows the percentage of
coverage.
- Identifies gaps, analyses reasons for gaps and
suggests solutions.
• The ASHAs will be trained to use the CDL Tool by the
RPs.
• The CDL Tool will be explained in detail in Module 5
of this Tool Kit.
Sukshema's Community Level Interventions 13
.' - i.-
SESSIONS:
IMPROVING THE QUALITY OF INTERACTION
IN PROVIDING HOME BASED MATERNAL,
NEONATAL AND CHILD CARE
SESSION 6:
ENHANCING ACCOUNTABILITY THROUGH
SUPPORTIVE COMMUNITY MONITORING
e
©
-
..
..
-
....
Objective
• To help the participants understand the concept,
importance and usefulness of the Home Based Maternal,
Neonatal and Care (HBMNC) Tool in monitoring the
mother and newborn.
Methodology
Small group discussion and presentation
Duration
1 hour
Training Materials
Markers and brown sheets/ card sheets
Tips for facilitators
ASHAs have the important task of visiting women
throughout the perinatal and post-natal period to seek
information from the mother and the newborn that can help
her screen them for any complications. The HBMNC Tool is
an important tool to help the ASHA monitor them and to
communicate the right messages at the right time.
;
:
:
■
Process
• Ask the participants what is the main responsibility of !
the ASHAs?
• Note their responses on a flip chart.
• Ask them to share and discuss the reasons and
responsibility of visiting homes from their own
experiences of working in the field.
• Note their responses on a flip chart.
• Consolidate the discussion by pointing out:
- Doing home visits is the ASHAs key responsibility.
■
- It is a crucial platform for communicating with
the woman and her family during the MN CH
continuum of care
j
- One of the main aspects of a home visit is to check
■
the condition of the woman during ANC and her
child during PNC and suggest appropriate services
I
and practices and steps to ensure that they are
healthy.
• Ask the participants how home visits are conducted
currently in the field and what the gaps are?
• Note their responses on a flip chart.
• Ask them to share and discuss the identified gaps.
• Highlight the gap of communication: either what to
communicate or how to communicate.
• Tell the participants that for ASHAs to
communicate well, they need to first understand
all the aspects of the MNCH continuum of care
thoroughly and to know the right messages at the
right stage:
- Antenatal care - care during pregnancy
- Intra-natal care - care during the delivery and
first two hours after the delivery
- Postnatal care (Mother and newborn) - care
during the first 42 days
- Child care - care of the child up to 5 years of age.
• Tell them that the HBMNC Tool has been
designed to address gaps in communication to
help the ASHAs improve the quality of their
interactions during home visits and help them
plan interventions in cases where the health of the
mother or newborn is at risk.
• Consohdate that the HBMNC Tool is essential in
maintaining a detailed record of every woman and
newborn across the MNCH continuum of care.
It can guide the ASHAs on what to be looking for
during each stage and helps them develop the right
message at the right time: informing women and
their famflies about high risk pregnancies, danger
signs during ANC, delivery and PNC periods, and
healthy practices in newborn care.
• The ASHAs will be trained to use the HBMNC Tool
by the RPs.
• The HBMNC Tool will be explained in detail in
Module 6 of this Tool Kit
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Process
Objective
• To help the participants understand the concept of
Supportive Community Monitoring (SCM)
• To help the participants understand the responsibility
of the community to ensure the adoption of healthy
behaviours and improve access to available services
by women and family members and the community's
responsibility to support the FLWs to be effective in the
field.
• To inform the participants about the Supportive
Community Monitoring (SCM) Tool.
Methodology
Discussion and group work
©
• Give one of the case studies to each of the four groups.
Case It
/the ASHA and JFA have not
Repeated
incing Ramappa to register
been successful ,
and bring his wife fore■heck-ups at the PHC
despite it being herfirstt pregnancy and she being
underweight. Every posssible attempt was made using
communication materiials, discussions withfamily
members and even brirttging the Medical Officer to
and accuses them that
their house. Hen
r pockets'. What can
theyforce women
be done?
Duration
2 hours
Training Materials
Brown sheets and markers
Case 2;
In Mudhol village, maternal deaths have happened
recently. This village is known for child marriage,
which is believed to be a traditional practice. FLWs
havefailed to convince families about the dangers of
marrying a girl before she is 18. Early marriage leads
to early pregnancy and delivery related complications.
What can be done?
Tips for facilitators
The focus of the session is to enable the participants
to critically think about the concept of supportive
community monitoring and its relevance to improving
MNCH and general health status of the village. Some
of the participants may not have worked with grass root
community structures and might find this concept new.
Take time to discuss and help them understand the role of
the community to enhance health outcomes at the village
level.
-
.
.
'
■'
'
'
■
'
.
Case 3:
The GirinagarPHC has not received anyMadilu kits
for the past 6 months from the GoK and the women
are demanding that they receive the kits. The villages
are. blaming the ASHA for this. What can be done?
‘
.-j
i f
Cased:
An SC/ST woman in Kavalur village is highly
anaemic. She is pregnant with her first child and her
husband has alienated her. Herfamily has refused to
accept her back into the house and she lives alone in
a hut with no means to feed herself. Her earning as
a daily wage labourer is very low. She needs a blood
transfusion to save the life of the baby. It will cost her
1500 Rs. What can be done?
Sukshema's Community Level Interventions 15
Ss
• Ask group members to read the case study in the
group, discuss and answer the question in each case
study.
• Allow 15 minutes for discussion, and then ask a
representative from each group to take 5 minutes to
read out their case study and share their responses to
the case study’s question.
• Ask other groups to share any other key information
about the case study.
• Continue with the next 3 case studies in the same
manner.
• Highlight any solutions that involve the villagers/
village heads/ Gram Panchayat members to resolve
the case study problems.
• Tell them that the larger community has a very crucial
role to play in ensuring the general health status of a
village, but that very often this role is undermined.
• Ask the participants that if they agree that the
community plays a crucial role in reducing maternal
and child morbidity and mortahty in rural villages
and how this source of help can be improved?
• Note their responses on a flip chart.
• Ask them to share and discuss their own experiences
of working in the field.
• Highlight any answers that involve the Village Health
Sanitation and Nutrition Committee (VHSNC). Make
sure all participants know about the committee and
its role.
• Tell them that the NRHM has recognized the
importance of community participation and
involvement in maintaining the health of the village
and have constituted the VHSNC to be in charge of
offering support to all health related activities at the
village level.
• One of the crucial roles of VHSNC is to support the
efforts in reducing maternal and infant morbidity and
1
i
I
mortality at the village levels.
• They can do this by supporting the efforts of the
FLWs using supportive monitoring of MNCH
continuum of care activities in the field.
• Divide the participants into two groups. Give each
group one of the following questions to discuss:
- What does supportive monitoring mean? What
activities could it involve?
- How can the VHSNC do supportive monitoring?
• Allow 15 minutes for discussion. Ask a representative
from each group to take 5 minutes to share their
answers.
• Ask the other group to contribute any other key
information about that question.
• Consolidate the session saying that the key to effective
community monitoring is “supportive” monitoring,
not supervising. The spirit behind the intervention is
‘fact-finding’ and ‘learning lessons for improvement’
rather than ‘fault finding’. Community feedback on
the status of functioning of the healthcare system and
service providers can facilitate corrective action and
enhance accountabflity to the community among
health care providers and community structures.
• Tell the participants that the SCM Tool has been
designed to help the VHSNC members to assess the
gaps in the field regarding access to and delivery of
MNCH services across the continuum of care. It will
then help them to strategize on what steps should be
taken locally to address the gaps. Monthly use of the
SCM Tool will help them understand the areas where
they need to support the FLWs.
• The VHSNC members will be trained to use the SCM
Tool by the RPs.
• The SCMT will be explained in detail in Module 7 of
this Tool Kit.
STAFF STRUCTURE, ROLES
AND RESPONSIBILITIES 3
AND DRAWING-UP AN
ACTION PLAN
Process
7.1 STAFF STRUCTURE
• Divide participants into three groups. Give them each the following
situations to role play:
- Seema is pregnantfor the second time and is in her seventh month.
During the first delivery Seema had obstructed labour. The ASHA
and JFA from Seema’s village are discussing how they would be able to
ensure that Seema goes to the PHCfor her delivery. What will the RP
do to help?
- Geetha is pregnantfor the sixth time and has five daughters. Her
mother-in-law thinks that since she has delivered for five times before
there is no needfor her to register so early. Geetha gets tired very
quickly, but cannot take rest as she is the eldest daughter-in-law of the
house. What are different issues that Geetha needs guidance on and
how will the RP help?
-Ina village, eight girls below 18 were married off over the last three
years. Three of them are pregnant now. The ASHA of the village is very
concerned about them. What will the RPdoto help?
• Allow 15 minutes to prepare their role play.
• After each group has performed their role play, ask all participants to
discuss the role of the RP.
• Display the ‘Overview of MNCH staff’ flowchart at the front of the
training room.
• Explain the existing MNCH staff structure roles.
• Ask the participants to return to their role play group and to
write down the roles of the FLWs based on the role play and their
experiences in the field on a flip chart.
• Allow 15 minutes for group work then ask a representative from each
group to display their flip chart on the walls of the training room and
to take 5 minutes to share their answers.
• Consolidate by stating that every level/staff has clearly defined roles
and responsibilities. Clarify that the ASHA, JHA and VHSNC will
directly work with the community and it is their responsibility to
create awareness, give the right message at the right time, and ensure
that all services reach the women across the continuum of care.
Objective
• To help the participants understand
the roles of the project staff at
different functional levels.
• Help the draw up an action plan for
the Sukshema project's activities.
Methodology
Group discussion
Duration
1 hour
Training Materials
Briefs for the role-play, brown sheets,
pen, pencils and sketch pens;
Background material 9: Staff structure
and responsibilities for under project
Sukshema, format 5: Profile of PHC/ SC
Tips for facilitators
Note that the staff structure presented
in this session is based on Sukshema's
experience in the field. This session
can be modified by users according
to availability of resources, scale
of project, funder support and the
roll out plan. It is important to build
role clarity so that the roles do not
overlap. The RPs need to understand
that they are not here to replace any
existing position, but to motivate and
support the ASHAs to do their work
responsibly and efficiently. Their role
is not supervisory, but supportive.
Sukshema's Community Level Interventions 17
OVERVIEW OF THE KOPPAL MNCH 'SYSTEM'
DHO
fc"-’
District
DPMO'
RQHO ; -r
Specialist
Resource Person
VHSNC
‘ ASHA/AW
THO
Taluk
PHC MO
PHC
ni
T
T
I
ASHA!W
ASHA / AW
ASHA / AW
•
a
F■ B
■ 'y
J
•
I
...
*.
iRg?
Village
■
7.2 DRAWING ACTION PLANS
• Ask the participants to return to their role play group
and to develop and write down on a flip chart their
action plan based on their specific roles for the next
three months in their respective areas.
• Allow 20 minutes for group work then ask a
representative from each group to display their flip
chart on the walls of the training room and to take 5
minutes to share their answers.
• If the training has a Taluk coordinator or a District
coordinator let them sit with the groups and plan how
they will initiate this process in the field.
• Their action plan can start with profiling their
PHC areas, gathering information about all FLWs
working in that area, rapport building with VHSNCs,
PHC staff and FLWs, preparing for ToT, briefing
health department officials about the project and its
interventions, etc.
• Give inputs on their presentations and help them
finalize their plans based on the stage that the project
is in and the scale at which the activities are going to
be launched.
18 Com.-nwiify Levei (ntervanttons /er improving Maternal. Neonatal and Child t
w
Sub-Centre
J HA
• Emphasize that the RPs role is to support them
with information, tools and providing guidance
in planning and NOT direct implementation. RPs
should not do a policing job, but support the FLWs
with affection, trust and team work
• RPs will conduct trainings for them on the following
community level interventions and support them to
roll out:
- Family focused Communication (FFC) Tool
- Community Demand List (CDL) Tool
- Home Based Maternal Neonatal and Care
(HBMNC) Tool
- Supportive Community Monitoring (SCM) Tool
• The RPs also have a responsibility to follow up with
the FLWs and analyse the outcome of the use of these
tools, the interventions on MNCH outcomes, and
ASHA tasks. This includes:
- Analysing the CDL Tool outcome through gap
analysis and problem solving tools
- Analysing the HBMNC Tool outcome and the
manner in which it is helping the ASHA do home
visits more effectively.
- Analysing the SCM Tool outcome and supporting
VHSNCs to implement the tool and take appropriate
action steps to work more effectively with the FLWs.
• RPs will use checklists that have been developed to
help them do these duties.
■.
..
District
I
■■" ;
. -1
' IB
..'-S
/•
•
.
■
.■
I .
. .
BOS
1
TRAINING EVALUATION AND FEEDBACK FORM:
SESSION 8: ? ...
TRAINING
..............
EVALUATION
Ml
AND FEEDBACK
■M.
BiMfM
....
. .-
S.No.
a
Objective
• To assess what affect the module had on the participants'
attitudes, knowledge and practice levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for enhancing
future effectiveness.
2
Training methodology and activities used
3
Training skills of the facilitators
4
Logistics at the training (Food, stay and comfort)
5
Relevance and usefulness of training
1.
30 minutes
2.
The training evaluation and feedback form will assess
what affect the module had on the participants' attitudes,
knowledge and practice levels and obtain feedback on the
usefulness of the training and suggestions for enhancing
future effectiveness.
Excellent
Good
Poor
List the three aspects of the training that you found most useful.
Reflection
Tips for facilitators
Subject
Training content and sessions
Duration
Training evaluation and feedback form
Name of the PHC:
1
Methodology
Training Materials
Place of training:
Designation:
Name:
Training dates: _
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
1.
2.
3.
What are the three most important lessons that you can take back to your work place from this training?
1.
Process
• Distribute the training evaluation and feedback form.
Go over all the areas that the participants will need to
think about while filling it in.
• Allow 20 minutes to complete it.
• Collect the training evaluation and feedback forms
from the participants.
• Before the closing ceremony begins, ask the
participants to share their feelings about the training:
encourage anyone who is keen to orally share two
positive aspects and two areas that need improvement
• At the closing ceremony thank all the participants for
their enthusiastic participation, congratulate them and
wish them the best as they go back to their own field
areas and begin to initiate the intervention on ground.
• Thank everyone else who contributed to the training
program. This might have included administrative
staff, venue owners, facilitators, guest speakers and
the organizers.
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
2.
3.
Please list suggestions for improved facilitation in future trainings.
1.
2.
3.
Sukshema's Community Level Interventions 21
I
■
I
L: ,
..
■
ANNEXURE 1 - Reading material
on village health and sanitation
nutrition committee (VHSNC)
2;.., -J.-
r—U. .. -
On the 12th of April 2005 the Indian government
started the “National rural health mission” (NRHM)
to safeguard and improve the health of all its citizens
especially the poor and those living in rural areas. Under
the aegis of this mission the government has started
several programs to improve the health of its citizens.
The government has put local community members
in charge of health services and has encouraged them
to formulate and oversee them in order to give the
people an opportunity to take decisions regarding their
health and to play a pivotal role in safe guarding it. The
supervision and planning of governments health plans
have been handed over to the community so that their
response to peoples needs and also their effectiveness
can be ensured. In this way the goal is to engender
a sense of ownership in stakeholders including the
government, community and NGOs.
PURPOSES:
1. For the government, Panchayat Raj institutions, and
the community to work together to achieve the goal
of ensuring equal partnership of the community in
improvement of health services.
2. Create an atmosphere where it is clear that it is the
community’s right to access health services and it is
the responsibihty of the government and concerned
departments to extend such services.
3. Identify the reasons why health services and various
health benefits are not effectively reaching the
community and importantly to women, children and
the weaker sections of the society.
4. Ensure that there is transparency and accountability
in the delivery system of health services and to
encourage them to effectively use the constitutionally
sanctioned platform of Grama Sabhas.
5. Clearly understand the intentions, goals,
organizational structure and best practices of the
mission and help the members with the knowledge,
skills and methods necessary to adapt it.
Al. VHSNC/VILLAGE HEALTH PLAN AND
MONITORING COMMITTEE:
• At the village level, the VHSNC will also function as
the village health plan and monitoring committee.
Formation and selection ofgeneral members
• The VHSNC/Village health plan and monitoring
committee will comprise of 15 Grama Sabha members.
Out of this there should be a minimum of 8 women
members and among the women members 3 of them
should belong to SC/ST and 2 SHG members. Among
the remaining 7 members, a minimum of 2 should be
belonging to SC/ST.
Ex officio members
• The Junior Female Health Assistant (JHA), the Junior
Male Health Assistant (JHA), the primary school
teacher (preferably women), all Anganwadi workers
(AWWs) and the Accredited Social Health Activists
(ASHAs) of that particular village will be the ex officio
members.
“Committee President”
• Only the local Gram Panchayat member can become the
ex officio President of the Village health and sanitation
committee/Village health plan and monitoring
committee.
• If that member is already the President of the local Gram
Panchayat, only he can become the ex officio President
of the Village health and sanitation committee/Village
health plan and monitoring committee.
• If the Gram Panchayat President is not a resident
of the village, then a Gram Panchayat member who
is a resident of the village can become the ex officio
President of the VHSNC/Village health plan and
monitoring committee.
• In case there are more than one Gram Panchayat
member in the village, then the Gram Panchayat has
to nominate one of them to be the ex officio President
of the VHSNC/Village health plan and monitoring
committee.
• If the Gram Panchayat is unable to decide on whom
to nominate, the chief executive of the local Taluk
Panchayat can select a suitable member from among
the concerned Gram Panchayat members to be the ex
officio President of the VHSNC/Village health plan and
monitoring committee.
• In such a situation, the decision of the chief executive of
the Taluk Panchayat will be final.
22 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
A2.4 COMMITTEE SECRETARY
A local ASHA worker who is the member of the
committee will be the secretary of the VHSNC/Village
health plan and monitoring committee. If there are no
ASHAs in the village the Anganwadi member will be
the member secretary. If there are more than one ASHA
or Anganwadi Worker, than the VHSNC/Village health
plan and monitoring committee is authorized to select
the senior most and able among them to be the member
secretary.
A2.5 MEMBERSHIP TENURE:
Among the 15 Gram Sabha members elected to the
committee, l/3rd of them will retire after the first year
and will be decided by a lottery. 5 new members from
the Gram Sabha will then be elected to take their place.
Similarly the remaining 5+5 members will retire after
the 2nd and 3rd years decided by the lottery and their
places will be taken similarly by other Gram Sabha
members. If the retiring member is from a reserved
category then the incoming member will also have to
be from the same category. The Gram Sabha will have
the discretion of re-electing a retired member. But
the members of the Gram Sabha should be aware of
the purpose and that is to give every capable member
of the village a chance to become the member of the
committee. The retiring and re- electing of l/3rd of its
members should be repeated annually. The supervision
of the retirement and re-election of the members must
be jointly done by the secretary of the local Gram
Panchayat and the doctor of the primary health centre
A3. RESPONSIBILITIES OF THE VHSNC
VILLAGE HEALTH PLAN AND
MONITORING COMMITTEE
• The VHSNC/Village health plan and monitoring
committee should every year prepare an annual
village health plan and a monthly report card and
submit it to the concerned PHC s health plan and
monitoring committee. In addition the committee
will also have the following responsibihties:
- Establish meaningful community monitoring
systems as per the directions of the Indian
government
- Arrange a quarterly health related people contact
program where there is a dialogue with the
community about health department services and
short comings if any, local solutions andsuggestions
on how to further improve the services.
- Engender an understanding in the community about
health services and health related rights.
- Prepare a village health plan to suit local realities
and necessities.
- Analyse current village health and care activities and
supply information to its concerned workers/officers
on how to make it better.
- Submit the annual village health report to the Gram
Sabha
- Submit the authentic and quahtative information
about the state of the health of the village to the
health plan and monitoring committee of the PHC.
- The management of the index numbers of the village
health records and the health information board
should be done regularly. The records and the board
should not only carry information about services
like pregnant women care and post natal services,
care for new born babies, vaccinations, nutrition,
etc., but also services aimed at people suffering from
contagious diseases and fife style related diseases
and Madilu, birth protection scheme, post-natal
care, mother’s care, etc., and complete information
about similar people oriented programs, which then
should be regularly updated. Information regarding
the visit dates of health workers to the village, venue,
etc., should also be provided to the people.
- Oversee the visit of health workers to the village on
the specified date and ensure complete health care to
the villagers.
- Organize people awareness campaigns about the
societal boundaries leading to forced abortions of
female foetus.
- Use of open funds: According to the periodic
directions given to the state government, the open
funds can be used and the monthly accounts have
to be submitted to the doctor at the primary health
centre and a copy of the accounts to the Gram
Panchayat.
- For the sake of village health related works every
Gram health and sanitation/gram health plan and
monitoring committee can accept help in the way of
money or in kind from institutions, Panchayat and
donors.
A.4 COMMITTEE MEETING:
• In the afternoon of the first Monday of every month
the committee should compulsorily meet and conduct
a meeting at any convenient place, for example
the Gram Panchayat office building/sub centre/
Anganwadi Centre/school building/community hall.
In an emergency, an extraordinary meeting can also
be called.
• The committee secretary has to send a notice along
with an agenda 3 full days before the date of an
ordinary meeting. An extraordinary meeting can be
called 24 hours after the notice has been sent.
• To conduct a meeting the quorum/members present
should be l/3rd the total number of members.
Among the members present, at least l/3rd should be
women.
• If there isn’t a quorum, the president should wait for
Sukshema's Community Level Interventions 23
30 minutes. If there is still no quorum, the meeting
should be postponed to a date convenient to everyone
in the same month and a fresh notice sent intimating
the new date.
• On the day of the meeting if the president is absent
and if there is a quorum, then a unanimous choice
from among the members present can function as the
president and conduct the meeting.
• The proceedings and decisions of the meeting have to
be recorded in an authentic book and the signatures
of the members present has to be affixed in it and the
copies of it have to be given to the PHC.
• The health plan and monitoring committee and the
secretary will have the responsibility of properly
maintaining the documents.
• The bank account of the VHSNC should jointly in the
names of the president and the secretary.
• Every three months the VHSNC/village health plan
and monitoring committee should submit a financial
and program report to the Gram Panchayat standing
committee.
• The village health and sanitation/village health plan
and monitoring committee should be the successor to
the Gram Sabha of the Gram Panchayat
• According to the Karnataka Panchayat Raj order 1993
61-A, the VHSNC/village health plan and monitoring
committee will have the position of a subcommittee
to the gram Panchayat standing committee.
paramedical and other staff. It acts as a referral unit
for 6 SCs. It has 4 - 6 beds for patients. The activities of
PHC involve curative, preventive, promotive and Family
Welfare Services.
Community Health Centres (CHCs)
CHCs are being established and maintained by the
State Government under Minimum Needs Programme
(MNP) / /Basic Minimum Services Programme
(BMS). As per minimum norms, a CHC is required
to be manned by four medical specialists Le. Surgeon,
Physician, Gynaecologist and Paediatrician supported
by 21 paramedical and other staff. It has 30 in-door
beds with one OT, X-ray, Labour Room and Laboratory
facilities. It serves as a referral centre for 4 PHCs and
also provides facilities for obstetric care and specialist
consultations.
First Referral Units (FRUs)
An existing facility (district hospital, sub-divisional
hospital, community health centre etc.), in addition to
all emergencies that any such healthy facUity is required
to provide, can only be declared a fully operational First
Referral Unit (FRU) if it is equipped to provide roundthe-clock services for:
• Emergency Obstetric Care including surgical
interventions like Caesarean Sections
• Newborn Care
• Blood Storage Facility on a 24-hour basis.
II
ANNEXURE 2 - Reading material
on Government infrastructure
related to healthcare
In the rural areas, the health care needs are primarily looked after by the outreach
services which are available at the basic unit of 1000 people by ASHAs and AWWs.
But the proper infra-structure of healthcare in rural areas has been developed as a
three tier structure based on predetermined population norms which are as follows:
For 2,50,000 to 3,00,000 people a Taluk hospital would
provide the health service infrastructure, while for aver
age of 20,00,000 people, this would be the District Hos
pital where specialists and emergency care and caesarean
section services are available.
ir:
Population Norms
Centre
Plain Area
H illy/Tribal/Difficult Area
Sub-Centre
5,000
3,000
Primary Health Centre
30,000
20,000
Community Health Centre
1,20,000
80,000
ANNEXURE3 Reading material o
Government schen
for mothers
and children
Under the National Rural Health Mission (NRHM)
several programmes/schemes have been intro
duced to reduce the incidence of maternal and
child morbidity and mortahty. Several important
programmes/schemes are:
1. Janani Suraksha Yojane
2. Madilu Yojane
3. Prasuthi Araike Yojane
4. Universal Immunization programme
5. Thayi card
6. Thayi Bhagya Scheme and Thayi Bhaya plus
scheme
7. Janani Shishu Suraksha Karyakrama
1. JANANI SURAKSHA YOJANE
Objective:
To provide financial support for families living
below the poverty line (BPL) and belonging to SC/
ST groups.
Primary programme components include:
• Early registration
• Micro / birth planning
• Referral transport (Home to Health Institution)
• Institutional birth
• Post-delivery visit and reporting
• Family planning and counselling
Source: MHFW (2005), Population Norms (Census 2001), http://www.mohfw.nic.in
Sub-Centres (SCs)
The Sub-Centre (SC) is the most peripheral and first
contact point between the primary health care system
and the community. Each SC is required to be manned
by at least one JHA and one Male Health Worker. The
SCs are provided with basic drugs for minor ailments
needed for taking care of essential health needs of men,
women and children.
Primary Health Centres (PHCs)
PHC is the first contact point between village
community and the Medical Officer. The PHCs were
envisaged to provide an integrated curative and
preventive health care to the rural population with
emphasis on preventive and promotive aspects of
health care. As per minimum requirement, a PHC is
to be manned by a Medical Officer supported by 14
24 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Eligibility of beneficiaries:
• Low Performing States (LPS): All pregnant
women. Above Poverty Line women delivering
in general wards of Government / Accredited
Private Hospitals
• High Performing States (HPS): All BPL pregnant
women, 19 years and above, up to 2 live births.
• LPS & HPS states: SC and ST women 19 years
and above, 2 live births delivering in general
Sukshema's Community Level Interventions 25
wards of Government or Accredited Private institutions.
• Home Deliveries: All BPL women of 19 years of age or above, up to 2 live births.
Category
; _
ASSIS^CE^C^
.........-
Urban
Rural
Mothers
ASHA
Mothers
ASHA
LPS states
1,400
600
1,000
200
HPS states
700
600
For two live births only
In both LPS and HPS states provisions for caesarean
section:
• Up to Rs. 1500/- per case for hiring services of experts
from private sector
• If private doctors are not available, utilization
permitted for providing honorarium/TA to
Government specialists, if available in another
Government facility provided s/he has the time to
spare and empanelled.
Other relevant information:
• The scheme is supported by ASHAs or any other
linked worker.
• Pregnant women have to register with the health
worker to avail these services. If not, they have to
have at least undergone three check-ups. They should
have also had 2 Tetanus injections and the prescribed
course of iron tablets.
endemic districts.
Other relevant information:
• Mothers who deliver in a private hospital are not
eligible for this service
• Pregnant women have to register at the SC and in the
local Health Centre well in advance
• BPL families that do not possess the BPL card have to
get authorization letter from the Revenue Department
Officer to avail of this service
3. PRASUTHI ARAIKE YOJANE
Objective:
• This scheme aims to address the nutrition deficiency
in SC and ST families by giving financial assistance to
encourage rest, provide access to nutritious food and
medical care during first and second live births for
BPL mothers.
2. MADILU YOJANE
Objective:
• To enable pregnant women with very low income,
especially from BPL families, to access Government
Hospitals for delivery
Eligibility of beneficiaries:
• Women from BPL families
• Women who have delivered in a Government
Institution
• Women with only two children
Assistance package:
• Under this scheme, a post-natal medical kit
containing 19 items for the safety and use of the
mother and child up to 3 months after the delivery, is
given as a ‘Tavarige udugore’ or gift from the mother.
The kit includes bedspreads, bathing soap, detergent,
etc. Mosquito nets are also supplied in malaria
a document ascertaining the beneficiary’s registration
(ANC) and if it is the 1st or the 2nd delivery.
• The delivery has to be compulsorily conducted at the
PHC/Government Hospital
• The beneficiary has to provide the doctor with a
photocopy of the caste certificate or a copy of the BPL
card.
Assistance package:
• Financial assistance of Rs.2000/- during Antenatal
period for BPL women that is given in two
instalments. The first instalment of Rs. 1000/- is given
during third trimester, and second instalment is given
immediately after delivery.
• An information booklet is given to all pregnant
women focused on the necessity of nutritious food.
Eligibility criteria:
• Pregnant women from SC and ST, BPL families,
living in the districts already identified by the State
Government are eligible, up to 2 live births.
Other relevant information:
• During every ANC visit, the women should get the
signature, date and seal of the PHC/Govemment
Hospital Medical Officer.
• The Junior Health Assistant (Female) has to provide
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
ANC REGISTRATION BOOKLET (THAYI CARD)
The Thayi card is a comprehensive ANC registration
booklet. It encompasses all the mother and child health
parameters from early ANC registration to post natal
follow up, immunization records of the child, weight
gain record, etc. These cards help in pregnancy track
ing and the immunization and growth of the child and
record the disbursement of the money for JSY/Prasuthi
Araike Yojane as well as the disbursement of Madilu kits.
THAYI BHAGYA YOJANE
Objectives:
• Despite in-sourcing/hiring of obstetrics, anesthesia
and pediatric specialists at FRUs, Karnataka is
experiencing shortage. However, the private medical
sector expertise is available and this scheme proposes
to tap this valuable resource. Private providers are
empanelled in identified districts to provide the
delivery care package. The private providers must
be screened by District Health Society. This scheme
enables cashless transactions for rural BPL families to
access delivery at recognized private hospitals.
Eligibility criteria:
• BPL women more than 19 years of age, for first two
live births, who have regular ANC check-ups.
Package:
• Private providers are reimbursed Rs.3,00,000 for
every 100 deliveries on a capitation basis i.e.RS.3000/per delivery, out of which Rs.250 + Rs.75/- will go
to transportation charges of the beneficiary and
accompanying person.
• This scheme is extended to Government institutions
up to FRU level. For Government institutions a
threshold is fixed on the basis of number of deliveries
conducted. This package is only applicable for
deliveries above the threshold level. Rs.1,50,000
for 100 deliveries will be paid as a package for
Government hospital i.e. Rs.1500/- per delivery.
JANANI SHISHU SURAKSHA KARYAKRAMA
Objective:
• This scheme is commonly known as JSSK and was
introduced by the Government in September, 2011. It
covers all women, with no difference linked to BPL or
APL.
Package:
• Access to ANC services and newborn services up to
30 days.
• Consumables /drugs (normal delivery or C-Section),
i.e., bandages, gloves, etc.
• Lab testing (ANC and newborn) i.e., X-Ray, blood
check, scanning, etc.
• Hospitalisation if required during ANC with food
when normal delivery for 2 days and C-Section for 7
days)
• Free vehicle support for transfer to higher facility
• No user charge in any Government institution.
Sukshema's Community Level Interventions 27
ANNEXURE 4 - Checklists for Sukshema's project field staff
__ ._______
2) CDL RP ANALYSIS FORMAT
1) CDL RP ANALYSIS FORMAT
CDL RP ANALYSIS FORMAT 2
CDL RP ANALYSIS FORMAT 1 MONTH: MATERNAL, NEWBORN AND CHILD INDICATORS
S.No i PHC name j Sub Centre ’ ANC
name
reg
I
I FA j ANC
Home I PNC I
Deaths
SUB CENTBE NAME.
delivery • visits
t
Maternal
Neonatal
Post
(0-28 day)
neonatal
(2»thday
y1
I
Reasons for
gaps in services
April
May
June
July ’ Aug i Sept
Oct
Nov
Dec
Jan
Feb March
1. ASHA workers visiting
pregnant women and
newborn
2. Ineffective
communication between
frontline workers
& beneficiaries
3. Unavailability of
ASHA/ANM/AWW
workers in the area
4. Incomplete ANC
services - IFA/TT
injections
5. Cultural practices and
beliefs
6. Families negatively
influencing the pregnant
women and mothers
7. Poor health seeking
behavior
8. Male preference
9. Inability to pay the
delivery cost owing to
poverty
10. Others
- formula tv denote ivd, yellow or-gfcriMnaark-acfoss a^fflf.shedndicator
-
-
Formula: Sum of Ach (Fulfilled)/'Sum of Target (Client needs) * 100
If the percentage obtained is less than 50% in that sub centre mark red, if the percentage obtained is
between 50%-75% in that sub centre mark yellow and if the percentage obtained is more than 50% then
mark green. In case of home deliveries reported in that sub centre area mark red even if there was one
home delivery reported. Mark green if there were no home deliveries reported. Similarly mark red even if
there was one maternal death reported in that sub centre. Mark green if there were no deaths reported in
that sub centre.
Red: Less than 50%
Yellow: 50-75%
Instructions: Sub centres listed in the RP Analysis format 1 having 3 or more than 3 indicators with poor
performing indicators (less than 50%) marked red are selected for further analysis in this format. The
probable reasons for gaps in services are listed in this format which should be identified every month and
marked (V) or else marked (x) if no reasons were identified. The issues identified should be discussed in the
Arogya Mantapa meeting and the group should arrive at problem solving approaches.
Green: More than 75%
Sukshema's Community Level Interventions 29
8
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3
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3) HBMNC TOOL HANDHOLDING CHECKLIST
Neirne cf'the RP:
ASHA ! Sub
Name ' centre
| Area
name
... Rapport
established
with the
women
G
Interacted I Examined
without
looking at
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word by
word
i the
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. newborn
I as
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messages
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j open ended
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is
F
I
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Yellow/
Red
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3
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4
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& has been !
recorded
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s
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; Message i Appropriate
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Informed
! was
was used for
communication
j about
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focused
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I
skills were used
{the
communication on
(Active listening,
further
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follow up
her family ; ended questions,
needed
| paraphrasing &
I other) skills have
been used
I
8
9
J,
10
11
12
13
14
15
Scoring: If score is 8 & above (Green): Good, 5-7(Yellow): Average, 4 & < 4(Red): Needs further support
4) SCM TOOL HANDHOLDING CHECKLIST
xxic--------
.• Name Members
J of the j participation
i village! was open &
•j free mind
I
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I
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sat in
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Discussion
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activity
planned in
the previous
meeting
Microplanning
was done after
the meeting
Mutual
cooperation
was
observed
All the
columns
are filled
& abstract
prepared
—
Members
are
discussion
without
the help of
RPs
Discussion
points are
brought to
the notice
of the
panchayat
& followed
up
SCMT
meetings
are
conducted
regularly
£
3
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I
§
i
I
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___
§
w
Scoring: If score is 8 & above (Green): Good, 5-7(Yellow): Average, 4 & < 4(Red): Needs further support
__
Tools are
filled only
after the
discussion
Color
Green/
Yellow/
Red
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32 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
FOUR
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
COMMUNICATION AND
COLLABORATIVE SKILLS FOR
FRONT LINE HEALTH WORKERS
ACKNOWLEDGEMENTS
Community Level Interventions for
Improving Maternal, Neonatal and
Child Health: Communication and
Collaboration for Front Line Workers,
is the fourth module of the tool kit in a
series of seven on enhancing community
engagement for improving outreach,
shaping demand and strengthening
accountability to improve maternal,
neonatal and child health outcomes in
Karnataka.
The following institutions and individuals contributed
to the idea, design, writing and editing of this tool kit:
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
Mr. Mohan HL, UOM
Dr. Suresh Chitrapu, KHPT
Dr. Seema Huddar, KHPT
Anna Schurmann, KHPT
Dr. Suresh Chitrapu, KHPT
Mr. Prathibha, KHPT
Mr. Somashekar Hawaldar, KHPT
Dr. Anindita Bhowmik, KHPT
Dr. Suresh Paschapur, KHPT
Nagaraj Ramaiah, KHPT
Dattatreya J ere, KHPT
Manjunath Dodawad, KHPT
Saleema, JHA, Koppal
Vijayalakshmi, ASHA, Koppal
Pavadamma, ASHA, Bagalkot
Sharada, ASHA, Koppal
Nirmala, ASHA, Koppal
Thulasa, Anganwadi Worker, Koppal
Mohan Chandra, U, KSTC
Samshuddin, KSTC
Srinivas NA, KSTC
COMMUNICATION AND
COLLABORATIVE SKILLS FOR
FRONT LINE HEALTH WORKERS
In Karnataka State the National Rural Health Mission,
the Department of Health and Family Welfare, and
the Department of Women and Child supported this
initiative.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & 5th Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91-80-40400200
Fax: 91-80-40400300
www.khpt.org
The following officials from the DEPARTMENT OF
HEALTH helped us in our efforts:
Mission Director, NRHM
DHO of Koppal and Bagalkot districts
RCHO of Koppal and Bagalkot districts
DPMO of Koppal and Bagalkot districts
Deputy Director, Women and Child Department of
Koppal and Bagalkot
All the taluk coordinators, resource persons, medical
officers and frontline health workers in Koppal and
Bagalkot Districts contributed to the process of
developing, piloting and rolling out this Tool Kit.
Year of Publication: 2014
Copyright: KHPT
THE EDITORIAL TEAM:
Mr. H.L. Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Mr. Suresh Chitrapu; KHPT
Ms. Dorothy Southern, KHPT consultant
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
The photographs are by KV Balasubramanya.
They have been used in the module with consent
from the community.
Improved Maternal, Newborn & Child Health
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PREFACE
The Community Level Interventions Training Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Health Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 4: Communication and Collaborative Skills for Front Line Health Workers
focuses on the Junior Female Health Assistant (JHA), the Accredited Social Health
Activist (ASHA), and the Anganwadi Worker (AWW), the three groups that are key
front line health workers (FLWs) in the Sukshema's project. The module will lead
them through sessions that will enhance their understanding about: gender and
social issues related to the acceptability and access to Maternal Neonatal and
Child Health (MNCH) continuum of care services; the importance of focussing on
the family as a unit for bringing about desired changes related to MNCH practices;
and addressing the gaps in coordination among FLWs in the field. Overall the
module aims to improve communication skills during outreach and interactions
with the pregnant woman, her family and the community through Family Focused
Communication (FFC) Tools, which can help FLWs value themselves and their
work, both when working independently or in a group.
CONTENTS
ACRONYMS
6
Getting Started: The Doorway to Successful Training
7
SESSIONS
Session 1: Underlying causes of mother and infant mortality
8
Session 2: Understanding family focused communication (FFC)
9
Session 3: Enhancing communication skills: five activities for FLWs
Activity 1: Skills to listen and comprehend
Activity 2: Using non-verbal communication and body language for expression
Activity 3: Improving ability to express through words
Activity 4: Overcoming barriers to communication
Activity 5: Moving from self-centric to people centric approach
11
11
12
13
14
14
Session 4: Understanding women and their status in the society
16
Session 5: Power walk
18
Session 6: Developing different perspectives
20
Session 7: Maternal and child care: Then and now
22
Session 8: Coordination and collaboration in the field
Activity 1: The three sisters.......................................................................
Activity 2: Our work and vision
Activity 3: Roles and responsibilities of FLWs
Activity 4: Coordination and cooperation for progress
Activity 5: Unity is strength
Activity 6: Arogya Mantap: building collaborative forums of FLWs
23
23
24
25
26
27
27
Session 9: Training evaluation and feedback
28
ANNEXURES
Annexure 1: Concept note on FLW collaborative forum
30
if -I
ACRONYMS
ANC
ASHA
AWC
AWW
BCC
BPL
CHC
CHW
DPM
DPO
EDD
FLW
FP
FRU
GoK
IEC
IMR
IPC
JHA
LBW
MDG
MMR
MNCH
MO
NGO
NRHM
PHC
PNC
SBA
SC
SC/ ST
SHG
TBA
TT
VHSNC
WHO
6
Ante Natal Care
Accredited Social Health Activist
Anganwadi Centre
Anganwadi Worker
Behaviour Change Communication
Below Poverty Line
Community Health Centre
Community Health Worker
District Programme Manager
District Programme Officer
Expected Date of Delivery
Frontline Health Worker
Family Planning
First Referral Unit
Government of Karnataka
Information, Education, Communication
Infant Mortality Rate
Inter Personal Communication
Junior Female Health Assistant
Low Birth Weight
UN Millennium Development Goals
Maternal Mortality Rate
Maternal, Newborn and Child Health
Medical Officer
Non-Government Organization
National Rural Health Mission
Primary Health Centre
Post-natal Care
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Self Help Group
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health and Sanitation Nutrition Committee
World Health Organization
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
GETTING STARTED
The Doorway to Successful Training in
Part 11 of Module 1 should always be
used to start a training workshop: initially
if covering all modules at one time, or
as a refresher if modules are scheduled
over a period of time. Ihe D<w»rway to
Successful Training contains a detailed
plan of sessions that sets the stage for the
workshop activities and logistics, covering
welcome, introductions, objectives, hopes
and fears, and ground rules.
»
<
SESSION 1:
UNDERLYING CAUSES
OF MOTHER AND
INFANT MORTALITY
<
Maternal death
during delivery
Infant death
Maternal death
Maternal death
---------- Maternal death
Process
1.1 CIRCLES OF INFLUENCE
Objective
• To help the FLWs understand the deeper social
realities that lead to a high MMR and IMR.
Methodology
Duration
Brainstorming and discussion
1.5 hours
Training Materials
Picture of tree, markers and brown sheets/ chart paper
Q
Tips for facilitators
This session focuses on helping the FLWs explore
the underlying causes of maternal and infant
illness and death using a socio-cultural lens. Some
participants may not immediately agree with this
approach, but take the time to use analytical
reasoning so they understand that both medical and
social causes have to be addressed using a holistic
approach. Convince them that change needs to
happen at the individual level, the family level and
the societal level to improve MNCH continuum of
care services in rural areas.
8
• Ask the participants, ‘Why do mothers and infants
die during child birth in rural India?’
• Encourage them to come up with ideas. Ask probing
questions until you get some responses.
• Note their responses on a flip chart.
• Highlight the four most commonly shared
responses.
• Ask the participants, ‘What could be the reasons
behind these main causes?’
- For example, deconstruct anemia, the causes of
which could be malnutrition, overwork, poverty,
lack ofawareness on nutritious food. Or deconstruct
malnutrition, the causes of which could be a woman
eats at the end ofthe meal when most of the food
has been eaten.
• Note their responses on a flip chart.
• Continue with the next two most common
responses.
• Tell the participants that most of the reasons for
causes for India’s high MMR and IMR have their
roots in gender discrimination and imbalances in
society.
• Most of the time we tend to look at MNCH
only from the medical point of view and ignore
the deeper social and cultural realities that are
responsible for MMR and IMR.
• Display the picture of the tree at the front of the
training room.
• Explain the social and cultural realities in the Indian
context using the picture.
• Ask all the participants to share similar experiences
that they know of in the course of their field work.
• Consolidate the discussion:
- When analyzed, ever}' cause of maternal and infant
death has social and cultural roots.
- Change needs to happen at the individual level, the
family level and the societal level.
- This holistic understanding should lead to
addressing both medical and social causes together
to bring about improvement in MNCH in rural
regions.
- Healthy mothers and babies reflect a healthy social
balance in the village.
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
; WSiS>MU. Bleeding <
Anaemia
7-7
i
Malnutrition-poor
breastfeeding
I
Child marriage
womb small
Cord sepsiscultural practice
Repeated abortions previouslymale child preference
Low caste worn a nso services not given
Neglect because
of a girl baby
SESSION 2:
UNDERSTANDING FAMILY
FOCUSED COMMUNICATION (FFC)
Q Tips for facilitators
Objective
• To help FLWs understand the importance of
communication focused on families.
Methodology
Duration
Brainstorming and discussion
1.5 hours
Training Materials
Markers and brown sheets/ card sheets
This session highlights the concept of FFC and its
relevance to MNCH. The current priority of the FLWs is
identifying family members who influence the pregnant
woman. The FLWs must ensure that strategic and focused
communication with these individuals takes place in a
timely manner so that their opinions, views and beliefs
are altered for effective behavior change, not just in the
pregnant woman, but in the family as a whole. Encourage
the FLWs to share experiences from the field at different
stages of the session to make the discussions realistic. Help
them understand that when communication is structured
responding to real social realities within families, it is
possible to change the decision makers behavior.
Communication and Collaborative Skills for Front Line Health Workers
9
t>
Process
• Share this story with the participants:
Within a few hours after delivering a child Kamalakka
dies on the way to the hospital due to severe bleeding.
Herfamily had her deliver her baby at home. The
grandmother believed the bleeding will take out all
the toxins within the body. She wasn't fed properly
during her pregnancy due to the fear that the baby
may grow too big for a safe delivery. Her mother-in
law made her do strenuous work to facilitate "easy
child birth”. Her husband wanted a male child, but
she already had three daughters in the last 4 years. But
Kamalakka died and now her children are motherless.
Ask the participants why Kamalakka died.
Note their responses on a flip chart.
Ask them what wrong beliefs led to her death.
Note their responses on a flip chart.
Ask them where these wrong beliefs come from?
Note their responses on a flip chart.
Display the picture of the concentric circles at the
front of the training room.
• Ask them who influences pregnant women/mothers
the most. Tell them to fill in the circles with people/
groups/ organizations that have influence on a
woman, her child and her health.
• Allow 10 minutes for discussion and encourage
everybody to contribute.
• Make sure everyone gives reasons for the influence
they have on the woman. For example, if they say
husband should be in the innermost circle, ask them
why they think so.
•
•
•
•
•
•
•
• Consolidate the discussion:
- The closest circle of influence on the mother or the
pregnant woman is her family.
- It is in the family that beliefs are reinforced and
practiced.
- Working with women in isolation will not give the
desired results.
• Ask the FLWs if they have ever worked with family
members?
• Note their responses on a flip chart.
• Ask all the participants to share similar experiences
that they know of in the course of their field work.
• Consolidate the discussion:
- The decisions that surround the woman, her
marriage, her pregnancy, delivery and child care are
often taken by family members.
- Behavior change communication should focus on
prominent members of the family who have an
influence on the pregnant woman and her decisions.
- Working with family members is crucial to ensure
they make the right decisions and to build a
supportive environment for the woman.
- Communication strategies for family members may
be different and need new strategies.
~ A mother in law may refuse to listen.
~ A husband may not even believe in institutional
delivery.
• Tell the participants that in the following sessions
they will learn more about communicating with the
family.
Circles of
influence on
the mother
and child
SESSION 3:
ENHANCING COMMUNICATION
SKILLS: FIVE ACTIVITIES FOR FLWS
Session 3 includes five activities/exercises to enhance the communication skills of FLWs to work with pregnant
women and their families to improve the mother and child’s health during the MNCH continuum of care. The
activities aim to help the FLWs be confident enough to communicate intelligently and sensitively with persons with
different personalities, beliefs and customs, and to find solutions for both expected and unexpected challenges in the
families. All the activities in the session are linked together and should be conducted in one session. A key aspect of
this session is to motivate FLWs to perceive their work not merely as a job, but as a commitment to the cause of saving
mothers’ and childrens lives. These activities should help FLWs explore their personal strengths and channel them
effectively so that their interactions with mothers and families are focused, relevant and powerful and that the FLWs
realize their full potential
Duration for all 5 activities: 4 hrs
ACTIVITY 1: LISTENING AND COMPREHENSION SKILLS
Objective
■O
• To help improve the listening skills of the FLWs during
interactions in the field.
• To know the difference between hearing and listening.
• To grasp information, remember what was said, and
comprehend the meaning.
• To be able to design communication messages based on
what they heard.
Methodology
Duration
Reading activity and discussion
30 minutes
(fiy Training Materials
One copy of a MNCH brochures for each group, e.g.,
project brochures, handouts or reading material on MNCH
care. Markers and brown sheets/ chart paper
d
Tips for facilitators
Some of the participants may feel that 650 words per
minute is impossible. Reassure them that to reach that limit
they need to practice improving their listening abilities
by continuous effort and concentration. Tell them that
there is also a link between how well you can listen and
how interested you are in the subject. A FLW who is not
interested in a conversation with a pregnant woman during
a home visit will not hear much. She won't be listening to
what is being said. Communication will not be effective.
10 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
IWI i
Process
• Divide the participants into four groups.
• Give each of the groups one copy of the brochure.
• Tell one person in each group to read aloud to the
group what’s written in the brochure for one minute.
Ensure that she reads loud enough for all her group
members to hear. Ask her to read with moderate
speed.
• Signal when they need to start and when it’s time
to stop reading. The signal can be a bell or a loud
“START” “STOP” announcement.
• Give each group a paper and marker. After one
minute of reading, tell the groups to make a list of the
words that they heard.
• Allow three minutes to write down the words. Ask a
representative from each group to share some of the
words their group heard.
• Highlight the importance of listening. Tell them that
psychological studies have proven that the human
brain is capable of listening to up to 650 words per
minutes.
• Ask the participants why they thought the exercise
was important?
• Note their responses on a flip chart.
• Highlight the difference between hearing and
listening. Hearing is merely the ability to perceive
sound Listening is something one consciously
chooses to do. Listening requires concentration so
Communication and Collaborative Skills for Front Line Health Workers 11
that the brain processes meaning from words and sentences. Listening leads to learning and retention and therefore
generates effective responses.
• Ask all the participants to share similar experiences of how listening helps in their work in the field?
• Consolidate the activity:
- First learn to be an effective listener.
- Make an effort to reach the maximum ability to listen to 650 words per minutes.
- Only when you listen can you internalize and understand each situation.
ACTIVITY 3: IMPROVING ABILITY TO EXPRESS THROUGH WORDS
ACTIVITY 2: USING NON- VERBAL COMMUNICATION AND BODY LANGUAGE FOR EXPRESSION
■Jjfc Methodology
Objective
• To help participants understand
that body language is important for
effective powerful communication
in their field work.
• Non-verbal communication
can be effective in helping the
women/families remember NMCH
messages better.
• The body language of the FLWs
can be utilized to make the
listeners comfortable and make the
communication powerful.
IV
Group reading activity and
discussion
Methodology
Group activity and discussion
©
Duration
45 minutes
Training Materials
Black and white/colour pictures/
photographs of some event with a
group of people doing something
Tips for facilitators
Participants should be encouraged
to communicate in such a way that
other people won't forget. To ensure
this, they can improve their body
language, use pictures, perform a
role play, or use interactive activities
to build interest in the topic and to
help women/families improve their
retention of the information.
Process
• Ask the participants if any of them can recollect
a picture or a photograph that they have always
remembered.
• If yes, give one or two of them a chance to share what
they remember about that picture.
• Ask them why they remember it so well.
• Let other participants share their reactions about
why we remember some things, but don’t remember
others.
• Divide the participants into four groups.
• Give each group one photograph that has captured
some human activity.
• Tell all members of the group to try look at the
picture for 10 seconds without batting an eyelid or
blinking.
• Say START and after 10 seconds, say STOP.
• Now ask all the members in each group to close their
eyes.
• Ask them if they can still see the picture in their
mind’s eye.
• Tell them to open their eyes.
• Tell them that scientific studies have shown that
information absorbed by the right side of the brain
will remain permanently with the individual and
80% of this information is grasped from non-verbal
forms of communication such as pictures, photos and
body language. This type of visual communication
is permanently stored in one’s memory and many
people find it easier to remember information gained
Objective
• To help the participants understand that
different kinds of verbal communication
can be more meaningful and a variety of
expressions improves the effectiveness
of communication.
from pictures, colors, music or postures, rather
through verbal communication.
• Tell each group to discuss what they thought was
happening in the photograph; the situation, who the
group of people were, what they might have been
saying, etc.
• Allow 5 minutes for discussion and then tell each
group to plan how to create a pose similar to what
they saw in their picture with their group members.
• Ask one group to come to the front of the training
room and to pose as in the picture.
• Ask the other participants to guess what the situation
might be about.
• Continue with the next 3 groups.
• Ask them what they have learnt from this session.
• Note their responses on a flip chart.
• Consolidate the activity:
- Communication can be powerful without saying a
single word.
- The use of our body to communicate is called body
language.
- A persons body language can either make other
people comfortable uncomfortable.
- Positive body language can generate a healthy
atmosphere for communication.
- Use of pictures and diagrams can be an effective
means of communication as pregnant women and
their families can comprehend/respond to a picture
or a photograph faster than to words.
12 Community Level Interventions for improving Maternal, Neonatal and Child Health: A Training Tool Kit
Duration
45 minutes
Training Materials
A brochure with any written material
on MNCH
d
Tips for facilitators
Tell the participants that just like a human
has the ability to listen to 625 words in a
minute, a human can also speak 125 words
in a minute. Speaking using different
pronunciations, tones and modulations
can make the communication interesting
and captivating. Having a variety of tones/
expressions will be helpful and effective
while conversing with a group of pregnant
women or their family members. Every
family or pregnant woman has unique
situations and communication has also got
to be uniquely tailored for them. Health
related information should be interspersed
with colloquial language to make the
communication effective.
tV
Process
• Divide the participants into four groups.
• Give each group one brochure and highlight one paragraph of
text that should be read
• Start with Group 1. Ask one member to read that text aloud.
Whisper to that person to read without showing any emotions at
all.
• After the reader from Group 1 finishes reading, ask the
participants what they felt about this kind of reading and why.
• Encourage discussion.
• Move to Group 2. Ask one member to read that text aloud.
Whisper to that person to read using a heavy colloquial/local
dialect.
• After the reader from Group 2 finishes reading, ask the
participants what they felt about this kind of reading and why.
• Encourage discussion.
• Move on to Group 3. Ask one member to read that text aloud.
Whisper to that person to read using a very high pitched fast
voice.
• After the reader from Group 3 finishes reading, ask the
participants what they felt about this kind of reading and why.
• Encourage discussion.
• Move on to Group 4. Ask one member to read that text aloud.
Whisper to that person to read using a very low pitched slow
voice.
• After the reader from Group 4 finishes reading, ask the
participants what they felt about this kind of reading and why.
• Encourage discussion.
• Ask the participants what they felt about the four kinds of
reading and why.
• Go back to Group 1: ask the reader to read in a very sad voice.
• Go to Group 2: ask the reader to read in a very happy voice.
• Go to Group 2: ask the reader to read in a very frightened or
scared voice.
• Go to Group 2: ask the reader to read in a very triumphant or
heroic voice.
• Ask the participants what they felt about the four kinds of
reading and why.
• Ask the participants which of these kinds of reading might be
most effective in the context of their work in the field.
• Ask them what they have learnt from this session.
• Note their responses on a flip chart.
• Consolidate the activity:
- Verbal communication should be tailored differently for
different people.
- Using a variety of ways to make verbal communication
interesting can enhance retention among listeners.
- FLWs often fail to impress their target audience with their
conversations because they do not make it attractive.
- An FLW who communicates well will be more confident of
reaching out to the community.
Communication and Collaborative Skills for Front Une Health Workers 13
ACTIVITY 4: OVERCOMING BARRIERS TO COMMUNICATION
@ Objective
• To help the participants learn
how to overcome barriers to
communication in the field and
use them to their advantage.
Methodology
Role play and
group discussion
(3)
Duration
1 hour
Training Materials
None
Tips for facilitators
FLWs should be mentally and physically prepared before
any home visit or interaction with pregnant women and
their family members. The must know the specific MNCH
continuum of care stage that they are dealing with and
all related information. If something goes wrong during
a home visit, they must remember to remain calm and
composed even when faced with adverse reactions from
the pregnant woman, family members or the community.
They should seek out people who support them and
who can influence family members if necessary. Patience
and a positive attitude will help FLWs to overcome
communication barriers.
Process
• Ask participants to share some personal challenges
they face in the field.
• Note their responses on a flip chart and display at the
front of the training room.
• Divide participants into 4 groups:
- Ask group 1 to discuss challenging situations that
they faced while addressing an ANC case, then to
choose one and prepare a 5 minute role play for the
larger group that highlights actions to overcome the
challenge and turn it into their advantage.
- Ask group 2 to do the same using the topic of
handling a deliver}'.
- Ask group 3 to do the same using the topic of
handling a PNC case.
- Ask group 4 to do the same using the topic of a rift
between ASHAs, JIIAs or AWWs in the field.
• Allow 20 minutes for discussion and role play
preparation then ask a representative from each group
to introduce the role play and then have the group
perform the role play.
• After each role play ask the participants watching
it to identify ways in which the challenge had been
addressed and if they thought this would be useful in a
field situation.
• Encourage participants to share any different ideas
about how the challenge could have been overcome.
• Continue on with the next 3 groups.
• Go back to the list of the challenges faced in the field
that they shared at the beginning of the activity.
• Ask them if these situations can be overcome by
appropriate use of both verbal and non-verbal
communication. Discuss each situation as a group.
• Consolidate the activity:
- Don’t be stressed out or taken aback by any setback in
communication or a regressive incident in the field.
- Barriers can be non-cooperative family members,
negative attitudes, people with different personalities,
beliefs, thought patterns, strange situations,
patriarchal family systems, etc.
- Get support from other FLWs or community
members.
- Having a calm and quiet demeanor, using supportive
body language, the right choice of words, and correct
knowledge can help to overcome barriers.
- Barriers can be overcome and turned into an
advantage, but this process sometime takes
continuous effort with a patient and positive attitude.
ACTIVITY 5: MOVING FROM A SELF-CENTRIC TO A PEOPLE-CENTRIC APPROACH
Objective
Methodology
Group question
activity, game and
discussion
• To help participants examine
their motives and intentions in
the work that they engage in.
Training Materials
None
(3
Duration
1 hour
Q Tips for facilitators
This activity is only a beginning of moving from a
self-centric to a people-centric approach. It sows the
seeds of thought about changing their perspective
from the natural disposition of being self-centred,
into being more of a person that is guided by social
responsibilities. After the circle game, make it clear that
finding a place in the circle should not have been the
priority. They became competitive instead of using this
opportunity to meet all the group members. Highlight
that their job responsibilities as FLWs is to reach out to
target groups and not focus on themselves.
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
IV
Process
• Ask the participants whom do they feel they are
working for.
• Note their responses on a flip chart and display at the
front of the training room.
• Tell the participants that they will take part in an
activity that involves a series of questions that they
need to respond honestly to.
• Ask the participants, ‘If humans were now living on
the planet Mars, and there was a fight between those
people living on Mars and those of us here on Earth,
who would you support?’ The majority will probably
answer Earth.
• Ask them why? The group might say, ‘Because it is
ours’.
• Ask them, ‘Now what if there was a fight between
India and Pakistan. Who would you support?’ The
majority will probably answer India. Ask them why?
• The group might say, ‘Because it is ours’.
• Continue asking the questions:
- “If there is a fight between north India and south
India?”
- “If there is a fight between Karnataka and Tamil Nadu?”
- “If there is a fight between our district and the
neighboring one?”
- “If there is a fight between our town and the neighboring
one?”
- “If there is a fight between our street and the next one?”
- “If there is a fight between our house and our neighbor?
- “If there is a fight between our father and our mother?”
• Although they probably had no problems answering
all the previous questions, now there might be a
dilemma.
• Insist on them answering the question, choosing
between their father or their mother. The majority will
probably answer mother.
• Ask them why? The group might say, ‘Because she is
like us’.
• Now ask if there were to be a fight between you and
your mother, who would you support? Most likely the
answer will be, “Me”.
• Remind them what they told you at the beginning
of the activity when they said that they worked
for mothers and children. Ask them if they are
contradicting themselves.
• Tell them that they need to reflect about who is it they
truly work for? They need to move from thinking
about themselves to truly believing about helping
mothers and children.
• Introduce a game that should clarify how a peoplecentred approach will benefit them in the context of
their MNCH work with the communities.
• Divide the participants into two groups. One group
participates in the activity and the other group forms
the spectators.
• Ask the spectator group to sit down around the
room.
• Ask one member of the group playing the game to
volunteer to step aside for the moment.
• Ask all of the other game participants to stand in a
circle with everyone facing inside.
• Now tell the volunteer to start walking around the
circle in the clockwise direction. Tell her after about
1 minute to touch somebody standing in the circle
on the back.
• The person who is tapped on the back needs to step
out of the circle and start walking anti-clockwise
around the circle. The people still in the circle should
not move, but leave that space empty.
• Tell them that when they both meet, they need to
introduce each other by giving their name, where
they live and which area they work in.
• Then they should try to get back to the one empty
spot in the circle.
• The participant who arrives first to the empty
place gets to take the place. The other participant
continues the game, by tapping a new person on the
back each time.
• Play the game until all participants have a chance,
then ask all participants to sit down.
• Ask the spectator group what they observed during
the game, giving three or four people the opportunity
to respond with different reactions. They might say
that they saw the participants were in a hurry to get
to the empty place first, so they rushed through the
introductions.
• Ask the group that played the game why the
place in the circle became more important than
introductions, giving three or four people the
opportunity to respond with different reactions.
• Consolidate the session:
- There is a difference between just a job and a
profession you feel passionate about.
- You must be committed to see change in the lives of
mothers and children.
- Actions can be driven by selfish motives.
- During work the focus should not be on personal
objectives, but on the needs of pregnant women,
their families and their communities.
- Becoming a people-centred individual is ultimately
an expansion of one’s own personality.
- It is important to develop an outlook that focuses
on peaceful co-existence and to building good and
lasting relationships with the mother, families and
communities.
- Use every opportunity to be a “people person”
rather than a “me-my life and myself” person.
Communication and Collaborative Skills for Front Line Health Workers 15
SESSIONS
UNDERSTANDING WOMEN AND
THEIR STATUS IN THE SOCIETY
SCENES FOR DISCUSSION
Social
• To help the participants critically analyse the
situation of women in northern Indian society
Methodology
Duration
Group work and discussion
1.5 hours
Training Materials
Picture of tree, markers and brown sheets/ chart paper
d|
Tips for facilitators
The participants should develop a deeper perspective
about the challenges faced by pregnant women,
including the issue of maternal deaths. For a FLW, an
unnatural death of a pregnant woman, a woman who
has just delivered a child or of a new born baby might
seem to be the fault of the woman herself, relatives, the
medical team. However, this assessment is superfidal
and fails to examine the deeper prevailing social
norms and practices that put women in a vulnerable
situation. A closer look can reveal that prevailing
regressive social trends are responsible for a lack
of knowledge, acceptability and access to services
throughout the MNCH continuum of care. This session
should encourage women to think about the realities
surrounding a woman's life in the northern Indian
•
society, especially in rural areas. Some women will find
it difficult to break out of their own sodal conditioning
and may not accept that anything is wrong at all. The
picture cards will present real life examples that might
convince them that there is inequality, and that this can
sometimes be very visible, or sometimes can manifest
itself in subtle ways.
’rocess
• Divide participants into 4 groups.
• Give each group 5 scenes, one from each category
(social, financial, religious, cultural and political).
• Ask the groups to think about and discuss the
scenes in detail.
• Tell them to answer the following questions for each
of the scenes:
- What situation does the stated scene illustrate?
- Could this situation happen in yourfield site?
- Share a similar incident that you have witnessed in
your field site.
- Why does this situation happen?
• Allow 20 minutes for discussion. Ask the group to
share the scene they thought was most important to
them. Ask a representative from that group to share
the scene and the answers to the question.
• Encourage all participants to share any different
ideas about the situation.
• Continue on with the next 3 groups, asking them to
choose a scene from a different category.
• Facilitate a plenary discussion:
- Are women lagging behind in many spheres of
life? Why?
- What are the major reasons for women being in
this situation?
- How deep is the society’s indifference towards
women? What have been the adverse effects of this
indifference upon their lives?
- What is the overall opinion of the group on the
current state of women? Why?
• Encourage the freedom to debate, express and talk.
• Consolidate the session:
- Society at large has been indifferent to the
inequality faced by women.
- In order to empower women to access MNCH
services as their right, they need to understand the
maze of rituals, practices, customs and traditions
that surround a woman’s life.
- FLWs should not reinforce negative beliefs and
practice, but should try to sensitively enlighten
pregnant women, their families and their
communities to whatever extent possible.
16 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Cultural
j
Political
■
4
tv
Objective
Religious
Financial
I
r
! Modem day
; A woman Panchayat
president sidelined
and her powers
usurped by her
husband
A boy or girl primary
student caring for an
infant or young child
Male wages are
more than female
wages
A woman banished
to the cowshed
during her menstrual
cycle
A drunken husband
beating up his wife
A woman who works
both in the fields and
at home
A widow with a
tonsured head
A tragic heroine film
star who is weeping
A woman's program
with the dais filled
with men
Mother-in law, father
in law and husband
pestering the wife for
dowry
Women in a family
that is migrating for
work
A new mother and
her new born baby
outside the house
because they are
impure
A woman breaking
her bangles after her
husband's death
Men controlling the
self-help groups
(SHGs)
A child being
married to an older
man
A female sex worker
A Devadasi woman
A woman immolating
herself on her
husband's pyre
A picture of a
situation where
the majority of the
agitators are SC/ST
women
A lower caste woman
working at a menial
task for an upper
caste woman.
Women are
dismissed from the
jobs for asking for
leave of absence to
have a child/care for
a child
A woman being
'punished' by
throwing coloured
water
magazine
advertisements as
opposed to rural
cultural appropriate
dress.
; A woman jumping
I into a lake
Woman being told
by her husband
whom to vote for
Il.
SESSION 5:
UNDERSTANDING WOMEN AND
THEIR STATUS IN THE SOCIETY
Process
Objective
• To help the participants understand how pregnant
women and their children have been systematically
excluded from opportunities to access MNCH
continuum of care services.
• To help FLWs understand how significant their role is
in linking women to services.
Methodology
Power walk activity
© Duration
1.5 hours
|a^* Training Materials
Identification badges with the roles written or drawn
on them, safety pins to attach these badges onto the
saris/ dresses, list of questions written down for the
facilitator to call out
Q
• Select 18 volunteers from the participants. Ask the
others to act as spectators who take note of what is
happening during the Power Walk activity.
• Ask the 18 volunteers to stand in a horizontal line in
a large spacious room.
• Mark a ‘goal’ close to the end of the room, which
ideally would be about 20 full steps away from
where the volunteers are standing.
• Place about 5 books on the ‘goal line’. Tell
the volunteers that these books represent the
‘government services’ that all people should have
access to and benefit from.
• Give each of the volunteers an identification badge
that tells them who they represent as in the table
provided.
• Tell the volunteers to attach the badges on their saris/
dresses using a safety pin.
• Tell the volunteers that:
- One: Whoever reaches the goal line’ will be able to
pick up a book that represents access to ‘government
services’ that will benefit their lives.
- Two: To reach the goal line’ they will have to answer
a series of questions. If the answer to that question
is a YES, then they can take one step forward. If the
answer to those questions is NO, then they need to
take one step backwards.
• Before you start asking questions:
- Demonstrate the size or length of an average step to
ensure fairness.
- Ensure that all the participants understand and have
internalized the roles that they are playing.
• Start asking with the questions in the table provided.
Ask them slowly, one by one, to allow the volunteers
to think about each and then decide to either take a
step forward or backward.
QUESTIONS FOR THE POWER WALK ACTIVITY
Is it easy for you to deal with the system in
government offices?
Are you earning any money every day?
Do you read the newspaper every day?
Tips for facilitators
Do you openly express your opinions at home?
Once FLWs understand and accept the unequal status
of women in Indian society, they can understand
how this inequality manifests itself through the lack
of opportunities to access MNCH continuum of care
services. Not all FLWs will initially agree that women are
marginalized, but through the real examples in the Power
Walk activity, they should be enlightened as they realize
that it was the men and influential people who were able
to access the 'government benefits', while the women
and marginalized groups could not reach the 'goal line'.
Encourage lots of discussion to highlight that FLWs are
not solely responsible for women not accessing MNCH
services, as many other factors are at play.
Roles for participants in the Power Walk activity
1. Married woman working as daily wage labourer
2. Rich woman living in a village
3. Illiterate woman from the village
4. Financially backward pregnant woman
5. Woman working as a domestic maid
6. Dalit woman
7. Old woman
8. Teenage Girl
Does anyone question you if you come home at 8pm?
Do you have to come home and work even though
you are employed outside?
Is it possible for you to spend the money you earn the
way it pleases you?
Have you got any personal savings in the bank?
Is it possible for you to access immediate medical
care as and when you fall ill?
Is your decision final with regard to your marriage?
9. Taluk panchayat member
Have you got the right to take decisions regarding
your family?
10. Village headman
Can you dress up according to your wishes?
11. Daily wage labourer at a construction site
Is it possible for you to take decisions regarding the
things that are dear to you?
12. Male politician
13. Newspaper reporter
Is it possible for you to visit the places that catch your
fancy whenever you want?
14. Village elder
15. Social worker
16. Farmer
17. Rich trader
18. Male government officer
18 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Is it possible for you to take up higher studies?
• As the questions are being answered everyone will see
that the 18 volunteers are standing at different lengths
away from the ‘goal line’.
• When the final question has been asked, perhaps only
one or two volunteers have reached the goal line’ and
have collected a book of government services’.
• For the remaining volunteers who are still standing,
tell them at the count of three to run towards the ‘goal
line’ and try to get a book.
• Count one, two and three. The participants who
were nearer to the ‘goal line’ will probably get the
remaining book.
• Ask everyone to sit down.
• First ask the spectators to share their experience of
the activity.
• Then ask the volunteers who were able to access the
books to come forward and tell the other participants
what role they had in order of first, second, third, etc.
• Ask the participants to discuss why each person
was able to reach the goal line and get access the
'government services’.
• Ask the volunteers who did not access the
‘government benefits’ to the other participants what
role they had in order of who was last, second to last,
third to last, etc.
• Ask all the participants if they think this situation
represents what happens in the field.
• Ask them what they can do as FLWs to help improve
the access of mothers and children to services.
• Consolidate the session:
- Basic rights of people are being denied because of
their marginalized status.
- It is crucial that MNCH continuum of care service
reach marginalized women
- The reasons why women and other groups are
marginalized are complex and linked to wider
societal issues.
- To ensure that benefits reach needy beneficiaries
instead of only those that are powerful and
influential takes continuous effort and commitment.
e a
• Most will count 16 squares.
• Tell them that there are more than 16.
• Ask volunteers to come up to the board and try finding
them. Give 3 or 4 participants a chance to find them.
• Tell them that there are 26 squares in total
• Discuss as a group.
• Ask them what they have learned from the discussions.
• Tell them that many times in many situations they have to
look carefully to find things that are not initially obvious.
Tell them this is especially true when we work with
pregnant women, their families and communities.
SESSION 6
DEVELOPING DIFFERENT
PERSPECTIVES
■
Process
Objective
• To help participants keenly and intensely observe a situation
and be able to see different perspectives and attitudes with
an outlook free from personal prejudices
Methodology
Games and discussion
|s^>*
O
Duration
45 minutes
Training Materials
A transparent glass half filled with water, white sheet of paper
with a black dot drawn in the middle, the two squares, a tea
cup with a handle, and markers and brown sheets
d
Tips for facilitators
This session has four activities that will help participants
understand that most of their decisions are shaped or
influenced by previous experiences, prejudices or social
conditioning in their lives. This hinders them from taking an
objective decision and examining a situation thoroughly and
analyzing it, thinking through possible options, and using
their best judgment. While working with pregnant mothers,
their families and the community, it is best to free themselves
of bias and prejudices. Although this is not possible in the
short term, it needs practice and encouragement.
"g] _
ACTIVITY 1:
• Fill up one transparent glass half full of water
and display at the front of the training room.
• Ask the participants, “What do you see?”
• Note their responses on a flip chart and
discuss.
• Ask them what they have learned from the
discussions.
• Tell them that the same glass has been
perceived by different people differently. If
they see it as a half- filled glass then they have
the opportunity to take the responsibility to
fill it up fully, just the same as if we see gaps
in MNCH services in the field, we need to fill
them and not expect somebody else to do it.
__
1
i
L
Ij
I ’ j '
I
I
ACTIVITY 2:
• Display the A3 sized white sheet of paper
with a black dot drawn in its corner at the
front of the training room.
• Ask the participants, “What do you see?”
• Note their responses on a flip chart and
discuss.
• Ask them what they have learned from the
discussions.
• Tell them that there are different perspectives
of the same thing. There is not always only
one way of understanding a situation. We
need to open to explore different ways of
seeing the same situation. If they only see
the small black spot, they are blinded to the
much larger white space. When they are in
the field, they cannot allow one negative
incident to ruin all their efforts. They need
to take all experiences, good or bad, in their
stride, while learning from every experience.
ACTIVITY 3:
• Draw 16 squares on the board as shown and
display at the front of the training room.
• Ask the participants to count the number of
squares and call out there answers.
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
ACTIVITY 4:
• Make all the participants sit in a circle on the floor and
place the tea cup in the middle of the circle.
• Ask each of the participants which side is the handle of
the cup facing. Some of them will say right, some left and
some centre and some behind.
• Discuss as a group.
• Ask them what they have learned from the discussions.
• Tell them that the truth is not only what is initially
obvious. They need to develop a holistic outlook or
perspective of situations. Then we they encounter
interactions in the field with pregnant women, their
families and communities, they will be able to effectively
communicate with them.
• Consolidate the session:
- What they see might not always be true.
- Their prejudices can influence their communication
negatively.
- Their outlook may not be holistic unless they probe into
situations deeply and objectively.
- They should learn to take negative situations as an
opportunity to improve.
Communication and Collaborative Skills for Front Line Health Workers 21
LU
1
SESSION 7:
MATERNAL AND CHILD
CARE: THEN AND NOW
Objective
• To help the participants understand the value of the
services and the assistance provided by FLWs.
(jP/
Methodology
Duration
Group work and discussion
1 hour
Training Materials
Chart paper and marker pens
Q Tips for facilitators
This session should help the FLWS understand the history and
development of services and benefits provided by the MNCH
continuum of care and the positive impact ensuring access has
had on the lives of mothers and children in rural India. In the
past when pregnant women gave birth, especially in rural areas,
there were hardly any services available and maternal, infant
and child deaths were on the increase. Although we can be
critical of government services, there have been a number of
advancements made to improve MNCH conditions. The FLWs
should realize the tremendous role they play in ensuring access
to MNCH continuum of care services and how they are linked to
every advancement to date.
Process
• Divide the participants into two groups.
• Give each group a chart paper and markers.
• Tell group 1 that they will explore ‘THE SITUATION
THEN’. Ask them to discuss and answer the following
questions:
- What was the situation of mothers and children in our
villages ten years ago?
- What were the services, benefits available for them then?
- What was the reality in the field surrounding pregnancy,
delivery and child care?
- What were the advantages and disadvantages of the
situation then?
• Tell group 2 that they will explore ‘THE SITUATION
NOW’. Ask them to discuss and answer the following
questions:
- What is the situation of mothers and children in our
villages now?
- What are the services, benefits and systems available for
fBSM
SESSION 8:
COORDINATION AND
COLLABORATION IN THE FIELD
St
W a
Session 8 includes six activities/exercises to enhance the coordination and collaboration of FLWs in the field.
Identifying existing challenges to working together and having a clear idea of their vision and purpose can improve
their interactions with pregnant women, their families and the community. The activities aim to help the FLWs
be able to coordinate their roles and responsibilities with all groups under the umbrella of FLWs so they can find
strength in unity. A forum that they can establish to empower their future activities is outlined and plans laid for
operationalization.
I
them now?
;
- What is the reality in the field surrounding
:
pregnancy, delivery and child care?
!
- What are the advantages and disadvantages of
■
the situation now?
; • Allow 20 minutes to discuss their topics and then
ask a representative from each group to display
•
their chart paper at the front of the training room
•
and to share the answers to the questions.
! • Encourage all participants to share any different
:
ideas about the situation.
■ • Continue on with the next group.
i • Ensure that all important changes that we see
!
today in relation to MNCH care are covered as
■
below:
•
- Mother and child mortality rates were higher
:
because of shortage of benefits and services,
!
Duration for all 6 activities: 4 hours and 30 minutes
ACTIVITY 1: THE THREE SISTERS
Objective
O
• To help participants understand the importance of
working together in the field.
superstitions, false beliefs, etc.
■
- Then there were no ambulance services
;
- There was no system of knowledge
:dissemination
>
- There was no distribution of nutritious food or
;
medicine
!
- There were no ASHAs
- There were no tools to help FLWs work better
■
- There was no stress on institutional delivery
;
- There were no equipment in PHCs and SCs
: • Ask them if maternal deaths and infant deaths
j
have stopped after all these positive changes.
:
They will say no, but highlight that the role
of the FLWS is crucial in ensuring that these
;
developments are used to the maximum in the
;
field until there is a significant decrease in the
:
MMR and the IMR.
: • Consolidate the session:
■
- Though people criticize the government, there
;
have been positive efforts to improve the lives of
mothers and children in the past decade.
;
- The existing benefits and services that have been
:
introduced throughout the MNCH continuum
:
of care have been fully discussed.
:
- One of the biggest achievements has been the
presence of ASHA, JHAs and AWW in the field.
'
- The role of the FLWs is critical.
22 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
t
Methodology
Duration
Screening of a short film, or
narration of the film's story and
discussion
1 hour
Training Materials
Copy of the film on a cd, LCD and screen, laptop, speakers,
brown sheets and markers
d
Tips for facilitators
This can be a sensitive session to handle as the ASHAs,
JHAs and AWWs may take it personally and jump to their
defence. They may attempt to deny that there are any
problems with working together in the field. Be tactful,
keep calm and reassure them that this session is not
intended to blame anyone, but to point out gaps that have
been noted during observations in the field. Even if they
have not experienced these problems, the suggestions for
positively working together can be beneficial to all.
Process
• Screen the short film after ensuring that all
participants can see the screen and can hear the
volume.
• If there is no provision for screening the film, then
read the story script slowly in a loud, clear voice.
Story of the three sisters
Thimmakka is in a good mood while eagerly waiting at
the doorfor the arrival of her three daughters. She stood
by the door reliving all her past: the struggles she faced in
bringing up the girls after theirfather had died when they
were very young; how her eldest daughter Suma began to
help her at a very early age; the strong bond between the
three siblings; their joy at having completed their studies;
how each one got a job; their marriage; and the pain of
seeing them leave her to be somebody else’s wife. All of this
flashed before her mind's eye.
The eldest girl Suma, even though she wanted to study,
had dropped out ofschool to help her widowed mother.
After completing her SSLC she took up the job of an ASHA
worker to support the family and let her other two sisters
complete their studies. The second sister Rama barely
completed her SSLC and refused to continue her studies
and became an Anganwadi teacher in a neighboring
village. The youngest Uma, with the assistance of her
two older sisters, completed her PUC and also the health
assistant course. She took up the post of a JHA in a distant
village. Thimmakka managed to find boys for each of her
Communication and Collaborative Skills for Front Line Health Workers 23
girls from the villages where her girls were working and
got them married off there. All her daughters usually come
home twice a year and spend a few days with her. The girls
arrived home and there was a lot of chatter in the house
with each one sharing all the news in their lives.
They finally sit down for dinner and begin to share about
the struggles each of them have been facing at work. Sumo,
the eldest girl, relates the problems she faces as an ASHA
worker. She talks about the disdain shown by the family
of the pregnant woman towards her, the non-cooperative
older Anganwadi workers in her area who refuse to even
acknowledge her presence in the village, the pressure that
the JHAs put on her to give them the information and do
reports at the end ofevery month, the unhelpful doctors.
To top it all off, they are all suspicions ofher husband's
family and the insecurities of her husband. Suma says that
her work experiences were making it very difficult for her
to continue her job as an ASHA.
The Anganwadi teacher, Rama also talks about the
problems she faces. Departmental pressure, the difficulty
in managing all the children in her Anganwadi centre,
the non-cooperative ASHA workers, the pressure from her
mother-in law to bring nutritional supplements form the
centre to their home on the sly, and the proud JHA in her
village who gives her no respect.
Uma, the youngest girl who is a JHA talks of the problems
she has with the ASHA workers and how so many of
them can barely read or write and never give her reports
on time, the pressure form the medical officer, noncooperative doctors, irresponsible family members of the
pregnant women, and all of the times she gets blamed for
everything that happens in a PHC and the ‘ungrateful’
villagers. She also tells the others that all these pressures
are forcing her also to think of quitting her job and be
at peace. Echoing her sentiments all of them agree that
this might be the best option for them. Thimmakka is
disappointed at hearing this and wonders what to tell
them.
• Divide participants into three groups.
• Tell group 1 to discuss Suma’s story and to answer the
following questions on a chart paper:
- Is it right or wrong for that sister to quit her job?
Why or why not?
- Would that sister have been able to solve their
problems if all the sisters were in the same village?
Why or why not?
- What would they suggest that this sister do to solve
her problems and begin to enjoy her work?
• Tell group 2 to discuss Rama’s story and to answer the
same questions on a chart paper.
• Tell group 2 to discuss Uma’s story and to answer the
same questions on a chart paper.
• Allow 20 minutes and then ask a representative from
group 1 so display their answers at the front of the
training room and to share their discussions.
• Allow other groups to share their comments about
Suma.
• Continue with the next 2 groups in the same manner.
• Consolidate the session:
- Despite differences FLWs need to work together in
the field.
- Respect and trust can build a good work
atmosphere.
- Only collaborative efforts can improve access to
MNCH continuum of care services in the field.
ACTIVITY 2: OUR WORK AND VISION
© Objective
• To help the participants understand their common goal
and vision
Methodology
Duration
Storytelling and discussion
45 minutes
Training Materials
Copy of the story
Q Tips for facilitators
This session can be sensitive as all the participants might
want to identify with ahd compare themselves with the 3rd
worker. They might deny that they could feel like worker
1 and worker 2. Point out that aspiring to always realize
the important role they play in ensuring access to MNCH
continuum of care services should make it easier for them
to have a positive vision, a good attitude, to enjoy their
work and respect their work colleagues.
Process
• Tell the participants to listen carefully while you share
a story.
A reporter working on a piece for his magazine, about
“what drives hard workers”, visits a stone quarrying pit.
There he watches workers toiling in the sun on the different
levels of the quarrying pit. He has the conversation with a
few workers he meets fhere.
Reporter to worker 1: What work do you do here?
Worker 1: Me? It’s my horrible fate that I landed here. My
only choice is to work here as a stone mason to feed myself.
24 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
The reporter speaks to the next worker.
Reporter to worker 2: What work do you do here?
Worker 2: Me? I am working here to feed my family.
ACTIVITY 3: ROLES AND RESPONSIBILITIES
OF FLWS
Objective
The reporter speaks to the next worker.
Reporter to worker 3: What work do you do here?
Worker 3: Me? I am working to build the most
beautiful mansion in town. Its a tough job, but then
when we are done, the building will make me proud.
• Ask the participants what is the difference
between the three workers’ answers?
• Discuss each of the workers’ answers.
• Ask them what their goals and sense of vision
are?
• Discuss each role if there are different categories
of FLWs in the workshop.
• Consolidate the session:
- The three workers were working towards the
same goal, but only the 3rd worker had a sense
of vision.
- The worker with a sense of vision also had the
right attitude towards his work and enjoyed and
respected what he did.
- FLWs should understand that their work is
important and that they should respect each
other for doing this job.
• To help the FLWs understand their specific roles and
responsibilities, the commonalities and differences
between other categories of FLWs and to see the
benefits in supporting each other towards a common
goal.
Methodology
Group work and discussion
Q
Duration
45 minutes
Training Materials
•
Brown paper, markers and tape
i • 'ips for facilitators
•
J
;
■
This session, focused on identifying commonalities and
differences, can help the FLWs feel more confident about
what they do. They will now know of practical ways in which
they can support each other in the field.
•O
Process
• Divide participants into three groups made up of the
ASHAs, the JHAs, and the AWWs.
• Give each of the groups brown sheets and markers
• Tell them to discuss and list down all their roles and
responsibilities.
• Allow 15 minutes to make this list and then ask the
ASHAs to display their list at the front of the training
room and to share the items they feel are most
important.
• Continue on with the JHAs and the AWWs.
• Now ask the whole group to look at all three lists and
to see if they can find some roles and responsibilities
that are repeated, or that overlap.
• Allow 10 minutes for all groups to highlight the
common roles by underlining them with a different
coloured marker.
• Discuss if these roles and responsibilities should be
duplicated or overlapping.
• If so, discuss how to find ways to prevent duplication
of activities, to cooperate and support each other in
the field, and to generate the collection of uniform
data.
• Consolidate the session:
- Roles and responsibilities have been discussed and
clarified
- Importance of avoiding overlap has been highlighted
- FLWs are able to see the benefit of supporting each
other in the field to carry out overlapping activities.
Communication and Collaborative Skills for Front Line Health Workers 25
ACTIVITY 6: AROGYA MANTAP: BUILDING
COLLABORATIVE FORUMS OF FLWS
ACTIVITY 5: UNITY IS STRENGTH
ACTIVITY 4: COORDINATION AND
COOPERATION FOR PROGRESS
(^) Objective
I
(^) Objective
• To help participants understand the importance of
coordination and cooperation among themselves to
achieve their goals in the field.
Methodology
Activity and discussion
Methodology
Activity and discussion
© Duration*
30 minutes
I
f
Cfc Tips for facilitators
Process
• Ask the participants to define the terms cooperation
and coordination.
• Note their responses on a flip chart.
• Display these definitions at the front of the training
room:
- Coordination: Co-ordination is the unification,
integration, synchronization of the efforts of group
members so as to provide unity of action in the
pursuit of common goals and purpose. It is a hidden
force which binds all the other functions of any
given group.
- Cooperation: The act of working together by giving
and receiving active assistance from each other that
builds trust, belief and a peaceful work environment.
• Ask one ASHA, one JHA and an AWW to volunteer
to take part in an activity. Tell the other participants
to watch.
• Place a strong chair before them and ask them to
stand on the three sides of the chair facing inside so
they can see each other faces (behind, on its left and
on its right).
• Now tell them to push the chair towards the direction
of the fourth side (forward) without changing their
positions.
Duration
45 minutes
MethodologyI
Duration
Brainstorming and discussion
45 minutes
Training Materials
None
A chair
O
Q
• To help participants understand the need and the
purpose of a collaborative forum for FLWs and how to
operationalize an Arogya Mantap.
Training Materials
Training Materials
FLWs face several challenges in the field, including lack of
cooperation by co-workers, indifference by village health
committees, and mistrust by family members. Ensure
that the participants are able to link this session to their
situations in the field. They will find that their work duties
are easier if they cooperate among themselves in order to
collectively face these challenges.
(<S^ Objective
• To help the participants understand that working
together brings strength and enjoyment.
• They will not be able to do it.
• Ask the participants watching to explain why they
were struggling.
• Discuss with the group.
• Now ask the three volunteers to turn and change the
direction that they face. Let all three of them face
towards the front.
• Now tell them to push the chair towards the direction
they are facing (forward) without changing their
positions.
• They will be able to do it.
• Discuss with the group why they could do it.
• Consolidate the session:
- In the first instance there was no possibility of
coordination because they could not collectively
channel their efforts. Their efforts were opposing.
- In the second instance they had a common vision
and could coordinate and help each other move
together towards that goal.
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Q Tips for facilitators
This game can get noisy and messy. Don't worry, but make
sure that the participants follow the rules. And ensure that
the message from this game is elicited clearly from them
after the game. The participants need to understand that
when they paired up, they became stronger and were able
to get more and more people to join them.
O
Process
• Ask the participants to walk around the training
room, making sure they do not bump into anyone.
• If they do, then they should join hands and continue
walking around.
• Allow a couple of minutes and then ask everyone to
increase their pace/speed of walking.
• If they bump into either a single person or a group
holding hands, they must join them.
• Allow a couple of minutes and then ask everyone to
increase their pace/speed of walking again.
• As the groups holding hands get bigger, more and
more people will bump into each other and join those
groups.
• When any one group reaches the target number of 8
people holding hands stop the activity.
• Ask all the participants to stand together in the
respective groups they were holding hands with.
• Ask them what connection they can make between
this activity and working together in the field.
• Discuss with the whole group.
• Consolidate the session:
- When workers are united they are strong
- When workers are united and strong, the job duties
become more enjoyable.
Chart paper and marker pens
Q
Tips for facilitators
This session is an introduction to the Arogya Mantap
concept. The follow up would be to ensure that at least
one project staff facilitates an Arogya Mantap in the
field. In the Sukshema's project in northern Karnataka,
the Arogya Mantaps are held at the SC level and all
the ASHAs, JHAs and AWWs that work under this SC
participate. However, this arrangement could vary in
different contexts. (See Annexure 1)
Process
• Ask the participants what they think they need
most to ensure that they can put the learning of this
training into practice.
• Note their responses on a flip chart.
• Highlight any responses linked to “meeting together
often to discuss work issues”.
• Use that response to bring in the concept of the
Arogya Mantap.
• Tell them that the Arogya Mantap is a collaborative
forum that is intended to offer FLWs a space
to meet, discuss and to share their learning,
experiences and challenges and work together to
address and generate joint solutions.
• Ask them why they need to come together.
• Note their responses on a flip chart.
• Divide participants into four groups. Ensure that
each group has some ASHAs, JHAs and AWWs in it.
• Tell each group to discuss the Arogya Mantap:
- What will its purpose and function be?
- Who should be part of it?
- When and where should members meet?
- How can it be useful to FLWs?
- What activities can it undertake to make it more
interesting?
- How should it be made operational?
- Who should be responsible for it?
• Allow 20 minutes for discussion then ask a
representative from each group to take 5 minutes to
Communication and Collaborative Skills for Front Line Health Workers Z1
share their most important points.
• Continue on with the next 3 groups in the same
manner.
• Encourage discussion on all points in the plenary.
• Distribute the Arogya Mantap concept note in
Annexure 1 and read it together.
• Ask the FLWs to decide on a date to begin the
Arogya Mantap meeting and choose either a SC or
a health facility as a venue.
• Tell them that one of the project field workers will
be present to facilitate the first Arogya Mantap
meeting in each of the SCs on the dates that have
been decided by the groups.
• Consolidate the session by noting that the Arogya
Mantap is:
- A collaborative forum that is intended to make
the work duties of the FLWs less stressful and
more productive by bringing FLWs together.
- Able to evolve according to the members’ need
and objectives.
SESSION 9:
TRAINING
EVALUATION AND
FEEDBACK
TRAINING EVALUATION AND FEEDBACK FORM:
KARNATAKA HEALTH PROMOTION TRUST
Training Evaluation and Feedback Form
<
Training dates:
S.No.
Objective
|
• To assess what affect the module had on the
participants' attitudes, knowledge and practice levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for
enhancing future effectiveness.
Methodology
££)
Reflection
Duration
Place of training:
____ Designation:
3 Name:
J
Name of the PHC:
Excellent
Subject
1
Training content and sessions
2
Training methodology and activities used
3
Training skills of the facilitators
4
Logistics at the training (Food, stay and comfort)
5
Relevance and usefulness of training
1
Good
Poor
30 minutes
List the three aspects of the training that you found most useful.
Training Materials
Training evaluation an'd feedback form
d
Tips for facilitators
The training evaluation and feedback form will assess
what affect the module had on the participants'
attitudes, knowledge and practice levels and obtain
feedback on the usefulness of the training and
suggestions for enhancing future effectiveness.
Process
1.
2.
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
1.
2.
3.
What are the three most important lessons that you can take back to your work place from this training?
• Distribute the training evaluation and feedback form.
Go over all the areas that the participants will need to
think about while filling it in.
• Allow 20 minutes to complete it.
• Collect the training evaluation and feedback forms
from the participants.
• Before the closing ceremony begins, ask the
participants to share their feelings about the
training: encourage anyone who is keen to orally
share two positive aspects and two areas that need
improvement.
• At the closing ceremony thank all the participants for
their enthusiastic participation, congratulate them
and wish them the best as they go back to their own
field areas and begin to initiate the intervention on
ground.
• Thank everyone else who contributed to the training
program. This might have included administrative
staff, venue owners, facilitators, guest speakers and
the organizers.
28 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
1.
2.
3.
Please list suggestions for improved facilitation in future trainings.
1.
1
2.
3.
Communication and Coliaborative Skills for Front Line Health Workers 29
C-
■iF
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1
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
IMPROVING THE
ENUMERATION AND
TRACKING PROCESS
Community Level Interventions for
Improving Maternal, Neonatal and Child
Health: Improving the Enumeration
and Tracking Process is the fifth module
of the tool kit in a series of seven on
enhancing community engagement for
improving outreach, shaping demand and
strengthening accountability to improve
maternal, neonatal and child health
outcomes in Karnataka.
ACKNOWLEDGEMENTS
The following institutions and individuals contributed
to the idea, design, writing and editing of this tool kit:
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
Mr. Mohan HL, UOM
Dr. BM Ramesh, UOM
Mr. Somashekar Hawaldar, KHPT
Dr. Suresh Paschapur, KHPT
Ms. Prathibha, KHPT
Mr. Arin Kar, KHPT
Dr. Suresh Chitrapu, KHPT
Dr. Navya R, KHPT
Mr. Vinod Kumar, KHPT
Mr. Raghavendra Kamati, KHPT
Dr. Rajeshwari, KHPT
Ms. Salima, JHA, Koppal
Ms. Renuka R, JHA, Koppal
Ms. Renuka, ASHA worker, Koppal
Ms. Gayathri, ASHA worker, Koppal
Ms. Rukmini, ASHA worker, Koppal
Ms. Pavadewa S Ganiger, Bagalkot
Ms. Padmavathi, Koppal
Ms. KR Sandhya, ASHA mentor, Koppal
IMPROVING THE
ENUMERATION AND
TRACKING PROCESS
The National Rural Health Mission of Karnataka
State, the Department of Health and Family Welfare,
Karnataka State, Department of Women and Child,
Karnataka State supported this initiative.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & Sth Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91 -80-40400200
Fax: 91-80-40400300
www.khpt.org
The following officials from the Department of Health
helped us in our efforts:
Mission Director, NRHM
DHO of Koppal and Bagalkot districts
RCHO of Koppal and Bagalkot districts
DPMO of Koppal and Bagalkot districts
Deputy Director, Women and Child Department of
Koppal and Bagalkot
All the taluk coordinators, resource persons, medical
officers and all the front line health workers in Koppal
and Bagalkot Districts contributed to the process of
developing, piloting and rolling out the Tool Kit.
Year of Publication: 2014
Copyright: KHPT
THE EDITORIAL TEAM:
Mr. H.L Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Dr. Navya R, KHPT
Ms. Dorothy Southern, KHPT consultant
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
The photographs are by KV Balasubramanya.
They have been used in the module with consent
from the community.
xIMPsukshema
Improved Maternal, Newborn & Child Health
or.
•>•
wrwfl JiriR
*
Ik
PREFACE
The Community Level Interventions for Improving Maternal, Neonatal and
Child Health Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
,
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 5: Improving the Enumeration and Tracking Process enhances the
capacities of the Accredited Social Health Activist (ASHA) and the Junior
Female Health Assistant (JHA) to identify, register and track all pregnant
women in her area across the Maternal Neonatal and Child Health (MNCH)
continuum of care. One of the key challenges identified in the field was the
absence of effective enumeration and tracking tools. This led to gaps in the
number of pregnant women accessing the full extent of services throughout
the MNCH continuum of care service. The Community Demand List (CDL) Tool
was developed specifically to identify which women in a specific area should
be given what services and when the next service is due. The practical handson introduction to this tool should improve utilization of all MNCH services by
all pregnant or recently delivered women and their newborns.
CONTENTS
ACRONYMS
6
Getting Started: The Doorway to Successful Training
7
SESSIONS
Session 1: Community Outreach for MNCH continuum of care
8
Session 2: Critical role of job aids and tools in outreach
9
Session 3: Challenges in outreach
10
Session 4: Introduction and practice of the Community Demand List (CDL1) Tool
10
Session 5: Introduction and use of the Community Demand List (CDL2) Tool
11
Session 6: Vulnerable groups: identification and problem solving
12
Session 7: Training evaluation and feedback
14
ANNEXURES
Annexure 1: Job aides and registers used by FLWs
16
Annexure 2: CDL1 Tool
16
Annexure 3: Guidelines for using the CDL1 Tool
19
Annexure 4: CDL2 Tool
22
Annexure 5: Definitions of indicators for using CDL2 Tool
24
Annexure 6: Demonstration of CDL2 Tool
26
Annexure 7: Gap Analysis Exercise
27
ACRONYMS
ANC
ASHA
AWC
AWW
BP
BPL
CDL
EDD
FLW
FRU
IFA
IMR
JHA
LBW
MMR
MNCH
MO
NRHM
PHC
PNC
PPH
SBA
SC
SC/ ST
TBA
TT
VHSNC
Ante Natal Care
Accredited Social Health Activist
Anganwadi Centre
Anganwadi Worker
Blood Pressure
Below Poverty Line
Community Demand List (CDL) Tool
Expected Date of Delivery
Front line health worker
First response unit
Iron and Folic Acid
Infant Mortality Rate
Junior Female Health Assistant
Low Birth Weight
Maternal Mortality Rate
Maternal, Newborn and Child Health
Medical Officer
National Rural Health Mission
Primary Health Centre
Post-natal Care
Postpartum Haemorrhage
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health and Sanitation Nutrition Committee
GETTING STARTED
The Doorway to Successful Training in
Part 11 of Module 1 should always be
used to start a training workshop: initially
if covering all modules at one time, or
as a refresher if modules are scheduled
over a period of time. Ihe Doorway to
Successful Training contains a detailed
plan of sessions that sets the stage for the
workshop activities and logistics, covering
welcome, introductions, objectives, hopes
and fears, and ground rules.
6
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
BE*
SESSION 1:
UNDERLYING CAUSES
OF MOTHER AND
INFANT MORTALITY
■
■
SESSION 2:
CRITICAL ROLE OF
JOB AIDS AND TOOLS
IN OUTREACH
.............
|^*
((•^ Objective
• To help participants understand the concept of
outreach and related activities linked to the MNCH
continuum of care.
Methodology
Duration
Group work
1 hour
Training Materials
LCD Projector, chart paper and markers
Q
Tips for facilitators
This session clarifies exactly what outreach is linked
to the MNCH continuum of care. This is critical for
the ASHAs as they are the 'experts' on the ground
and take the lead in delivering services.
Process
• Divide participants into four groups. Ask them to
discuss and answer the following questions:
- How would you define outreach?
- What are the objectives of outreach activities in
the context of the MNCH continuum of care?
- What are the current challenges in outreach?
• Allow 15 minutes to discuss, then ask a
representative from each group to share the
main points.
• Continue on with the next 3 groups.
• Display the following definition of MNCH
continuum of care at the front of the training
room:
- Antenatal care (ANC) - care during pregnancy
- Intra-natal care - care during the delivery and
first two hours after the delivery
- Post-natal care (PNC) - (Mother and newborn
care during the first 42 days
- Child care - care of the child up to 5 years of age.
8
• Display the following definition of outreach on a flip
chart at the front of the training room:
Outreach is providing health education and services
related to the MNCH continuum of care that can be ac
cessed by pregnant women, recently delivered mothers,
and mothers ofchildren under 5 years old, along with
theirfamilies and the community.
• Reinforce the need to providing continuous MNCH
continuum of care services.
• Highlight the factors which determine a complete
MNCH continuum of care:
- All pregnant women in a village should be registered
- All pregnant women registered should have received
all the ANC care services.
- All the new mothers and newborns should have
received all the PNC care services.
- All the children up to 5 years of age should have
received all the Child care services.
• Ask the participants what are the most common
MNCH services that rural women do not have access
to?
• Discuss the reasons for this gap in service delivery.
• Discuss the gaps related to current challenges in
providing outreach.
• Ask which health care workers are responsible for
reaching people in rural areas/villages to provide
health related information focused on MNCH?
• Discuss roles and responsibilities of FLWs, focusing
on ASHAs.
• Highlight the importance of ASHAs fulfilling their
key responsibility by delivering comprehensive
MNCH outreach.
• Consolidate the activity:
- A common understanding/definition of MNCH
community outreach was agreed
- Providing outreach related to the MNCH continuum
of care was acknowledged as challenging, yet crucial.
- ASHAs were recognized as the most important
FLWs in terms of reaching people in the village and
providing MNCH related information.
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Objective
• To help the participants understand the need for job aids
and tools that will contribute to the planning of outreach
and to critically review the current job aids and tools in
use and identify the gaps.
Training Materials
d
Methodology
Duration
Case study, small group
discussion, plenary
presentation and discussion
1 hour
Tips for facilitators
The facilitator needs to engage the ASHA in a critical thinking
process so that they recognize the need for job aids and tools
that can help them do their job more effectively and efficiently.
Copy of case studies, markers and brown sheets/ chart
paper, Job aides and registers used by FLWs (Annexure 1)
Process
• Give each group one of the two case studies.
BIH Case study 1:
A 24 year old married woman named Kamala had a
child after one year of marriage. The ASHA in the village
visited Kamala and described differentfamily planning
methods to the married couple. The couple decided to try
the copper T method offamily planningfor birth spacing
between their next plannedfor child. After three years,
& the couple decided to have their second child. Therefore,
Kamala had the copper T r intrauterine device removed
and she conceived again. The ASHA took Kamala to the
!
JHA to be ANC services. Kamala’s last menstrual period
(IMP) was on 20/5'2011. The first ANC check-up was
done by the JHA. However, Kamala missed the next
A . rrr* check-up.
Im Kamala
ri
r’/.ue.y
i lt£*l
ANC
went ?>•
into
labour
close to her due
1
date and delivered at home. However, two hours after she gave birth she experience postpartum haemorrhage
1
and died. The ASHA recorded Kamala's death and
1
registered
registeredthe
thenewborn
newbornitifin!
infantfar
forPNC
PNCservices,
services,indudiug
including
■
immunisations.
immtmistitions.
Case study 2:
A 24 year old woman, Gauramnm, was married on 1st
:
January 2011. Iler menstrual periods stop'ped after three '
months on 1/4/2011. She was taken to the JHA byfamily :
members to have a urine pregnancy test (UPT). Her
pregnancy was confirmed. The JHA registered the woman [
and provided the Phayi card on 3/7/2011. lhe 'Ihayi card '
number provided was 9800821. lhe first ANC check-up
was done and Gauramma received a TTl injection and
iron and folic acid tablets. Gauramma had a normal
delivery or, 20/1/2012 at the basest PHC to her home., lhe
ASHA in her village did the first PNC visit on 23/1/2012.
Alter one and half month the ASHA visited again and
the infant was given the first dose of Diphtheria, Tetanus
Toxoids and Pertussis (DTP), oral polio vaccine (OPV)
and Hepatitis.
■
■■'B
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• Ask group members to read the case study in the
group, discuss and answer the following questions:
• What registers do you use to fill in the information
of this case?
• How do you develop a follow-up plan to provide
MNCH continuum of care services?
• Do the current registers help to plan your outreach?
How?
• What changes in the registers would improve outreach?
• Allow 20 minutes for discussion, then ask a
representative from each group to take 5 minutes to
read out their case study, share their responses to the
case study’s question, and share the list of registers that
they are currently using.
'
• Ask the other group to share any other key
information about the case study.
• Continue with the next case studies in the same
manner.
• Distribute Annexure 1 Job aides and registers used by
FLWs.
• Highlight all the job aids and tools that have been
identified as being used by the ASHAs.
• Add or delete according to the participants’ context in
the field.
• Consohdate the session:
- Gaps of the job aids and tools have been identified.
- Suggestions have been made for changes in the job
aids and tools to improve outreach.
Improving the Enumeration and Tracking Process
9
E
SESSION 4:
INTRODUCTION AND
PRACTICE OF THE
COMMUNITY DEMAND
LIST (CDL1) TOOL
SESSIONS:
CHALLENGES IN
OUTREACH
((•)) Objective
Objective
• To identify critical challenges faced by ASHAs in
conducting outreach
(sj/
Methodology
Duration
Group work and presentation
1 hour
Methodology
Group work and discussion
Training Materials
Copies of the Job aides and registers used by FLWs
(Annexure 1), chart paper and sketch pens
d
• To introduce the Community Demand List (CDL1) Tool
to the participants and to facilitate a participatory
practice session of entering details of pregnant women
and newborns into CDL1 Tool.
Tips for facilitators
Ensure that the discussions are connected to the core topic
of improving outreach. FLWs may share personal grievances
such as issues around salary payment or other factors which
may not be directly under the control of the project. Keep
the group focused on outreach.
;
;
;
• Divide participants into two groups.
• Ask each group to review the job aides and registers
commonly used during outreach work as identified in
Session 2. (See Annexure 1)
• Ask group members to discuss the following question:
- What are the current problems and challenges
in ensuring complete entry and continuity of all
MNCH services to the target populations?
• Allow 20 minutes for discussion. Ask a representative
from each group to take 5 minutes to share their
answers in plenary.
• Ask the other group to share their answers and
compare key information.
• Highlight the challenges they face.
• Brainstorm what they think is essential to meet these
challenges and improve outreach.
• Note their responses on a flip chart.
• Consolidate the session:
- Gaps in outreach can be overcome by developing
a plan for ensuring entry of continuum of care
services for all target groups at the village level.
2 hours
Copies of the CDL1 Tool (Annexure 2) and Guidelines
(Annexure 3)
Tips for facilitators
Before this session, thoroughly review the training
materials, including Annexures 1,2 and 3, to be able to
lead this participatory hands-on exercise. Do not expect
the participants to understand the tool completely at this
juncture. Assure them that they will be able to acquaint
themselves more through practical exercises in the field.
Process
Process
;
;
■
:
•
■
I
■
;
I
• Discuss the purpose and uses of the CDL1 Tool.
• Some of the uses are:
- Reduces workload of the ASHA: reduces time in
filling in multiple formats
- ASHAs may ndt need to refer to as many registers
to get information about one beneficiary
- Tool is easy to carry from one place to other
- Less educated ASHAs can also use this format easily
- Helps in providing timely health services to all
target populations
- Can track women who migrate
- Can help plan outreach as the CDL1 Tool gives
information about all beneficiaries and all
important indicators in one place.
- Helps prepare monthly plans for follow-up based
on the understanding of who is due for what
services.
- Enables ASHA to prepare a list of beneficiaries
10 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
entered in their earlier job aides and registers. Tell
them to transfer the details of that case into the CDL1
Tool.
• Allow 20 minutes for group work and discussion.
• Ask a representative from each group to take 5
minutes to share the case they were using and the
process of transferring the details into the CDL1 Tool.
• Continue with the next 3 groups in the same manner.
• Clarify any misunderstandings.
• Consolidate the session:
- The CDL1 Tool will ensure complete entry and
continuity of MNCH care by helping the ASHAs to
develop a plan for tracking pregnant women in the
village.
- The four sections of the CDL1 Tool: Identification
details; ANC details; PNC details and Immunization
details need to be filled in completely for every'
pregnant woman in the ASHAs area.
Duration
Training Materials
d
;
;
;
(3)
requiring services
- Helps track the services due and the services
received by every registered person from pregnancy
to delivery and until the baby is 18 months old.
- Helps ASHA self-evaluate and reflect upon her own
performance.
• Distribute the CDL1 Tool to every participant (See
Annexure 2).
• Distribute Guidelines on how to fill-in the CDL1
Tool. (See Annexure 3)
• Review the CDL1 Tool by reading through each
section and explaining every indicator in each of the
sections/ columns in the tool.
• Demonstrate the entry of pregnant woman and
newborn details in each column of the tool based on
the example provided in the tool.
• Divide the participants into four groups.
• Ask each group to pick one case of a pregnant woman
SESSION 5:
INTRODUCTION AND USE OF THE COMMUNITY
DEMAND LIST 2 (CDL2) TOOL
(^) Objective
O
• To introduce participants to and provide hands on
experience of using the Community Demand List 2
(CDL2)Tool
• Distribute the CDL2 Tool to each participant
(Annexure 4).
• Highlight the objectives and uses of the CDL2 Tool
focussing on the importance of self-planning and
self-review.
- Serves as a self-reflection and review tool. It has a
list of 16 indicators derivedfrom the CDL1 Tool.
It helps the ASHA to identify and list only those
indicators that are very critical to MNCH care such
as registration of the pregnant woman, TT injection,
PNC visits, family planning, etc. 'lhe CDL2 Tool is
designed to help the ASHA carry out self-assessment of
the progress she has made on these critical indicators,
develop apian to effectively address the gaps seen,
evolve her monthly action plan, reinforce her personal
targets, and engage in constructive reflection of her
performance and challenges.
- Provides the ASHA with information about
beneficiaries due for services during the month as
well as tracks those who have received services during
that month. CDL1 Tool has the list of the names of
the beneficiaries. However, CDL2 Tool only has the
Methodology
Duration
Group work and discussion
1.5 hours
Training Materials
Copy of the CDL2 Tool (Annexure 4) and Definition of
Indicators (Annexure 5) and Demonstration of using CDL2
(Annexure 6)
a Tips for facilitators
Before this session, thoroughly review the training
materials, including Annexures 4, 5 and 6 to be able to lead
this participatory hands-on exercise. Resource persons (RPs)
should assist the groups with practicing the use of the CDL2
Tool.
Process
Improving the Enumeration and Tracking Process 11
corresponding serial numbers. Therefore the ASHA
does not need to write the names ofthe beneficiaries
each time that she identifies their service due in this
format. The CDL2 Tool is expected Io be filled in by
the ASHA the 21st of every month as her reporting
period isfrom the 21st to the 20th of the next month.
The process involves transferring the details of
pregnant women and newborn from the CDL1 Tool to
the CDL2 Tool.
• Distribute the Definition of Indicators to each
participant (Annexure 5).
• Explain that for every indicator in the CDL2 Tool,
there are defining targets and achievements. These are
a standardized process and all indicators are listed.
• Divide the participants into pairs. Tell each pair
to transfer the details of at least 10 to 15 pregnant
woman from the CDL1 Tool to the CDL2 Tool.
• Allow 20 minutes.
• Distribute Demonstration of using CDL2 (Annexure
6) to each participant.
• In plenary, use the example provided in the
demonstration tool as a reference for cross checking
this documentation exercise.
• Ask the participants about their views on the CDL2
Tool: how does it help them to improve outreach of
MNCH services? 1
• Consolidate the session:
- The CDL2 Tool documents beneficiary information
and serves as a self-reflection and self-review tool
to assess performance for that month and identify
strategies to fill gaps.
-
J
SESSION 6:
VULNERABLE GROUPS:
IDENTIFICATION AND
PROBLEM SOLVING
(^) Objective
(sy'* Training Materials
• To help participants identify the reasons for gaps in the service
provision, to identify vulnerable groups, and to suggest
solutions to the problems.
Filled in CDL1 Tool and CDL2 Tool, chart paper and
marker pens, copies of the Gap Analysis Exercise
(Annexure 7)
■jJj-
Methodology
Group work and discussion
(3?
Duration
2 hours
Q
Tips fof facilitators
This session can be facilitated at various levels: it
can be carried out with a group of ASHAs in the
village, but it is recommended that this session
be presented at the SC level so that the FLWs can
understand the overall SC's performance in terms
of service provision. This session demands close
engagement of the facilitator. The participants
could feel frustrated at the sudden emphasis
on formats and numbers which is analytical and
demands close attention. The ASHAs probably
have never engaged in this type of exercise before.
Ensure that you allow them to freely express their
doubts and fears. Be patient and engage them in
energizers if they are fatigued.
12 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
O
Process
• Ask them to review their filled in CDL1 Tool and
CDL2 Tool.
• Ask them which pregnant women have missed
services?
• Tell them that women who often miss out on services
are called vulnerable groups.
• Ask them who might be considered vulnerable in
their areas.
• Note their responses on a flip chart.
• Highlight that the following women could be
considered vulnerable:
- Pregnant women who have not been registered and
are already in the second trimester at the time of
tracking.
- Pregnant women with more than three gravida and
poor birth spacing with the age of last child within
12 months.
- Pregnant women who belong to SC/ST category and
have a Below Poverty Line (BPL) status.
- Pregnant women below 18 years.
- Pregnant women who have repeatedly missed
scheduled ANC services which include TT
injections, IFA tablets and ANC check-ups
- Pregnant women with a previous history of
complications in pregnancy/delivery.
- Pregnant women with complications in the current
pregnancy.
- Mothers who have not received counselling and
PNC care post-delivery’.
- Mothers who have currently delivered at home.
- Newborns who have missed the scheduled
immunisation doses.
- Any woman with a reported infant death(s) in the
remarks section.
• Display the Flowchart for using the CDL1 Tool and
CDL2 Tool and explain the process.
• Divide participants into four groups.
• Distribute one copy of the Gap Analysis Exercise
(Annexure 7) to every group.
• Ask the groups to fill in the form listing the
vulnerable groups and specifying the possible reasons
for each gap. Tell them to categorize the reasons as
either:
- External (if the reason for gaps in services is due to
the poor health seeking behaviour of the pregnant
woman and her family); or
- Internal (if the reason for gaps in services is due to
lapses from service providers side.
• Then ask them to analyse the gaps in services and to
suggest solutions for these problems.
• Allow 30 minutes for discussion. Ask a representative
from each group to take 5 minutes to share their most
important points and solutions.
• Ask other groups to share any other key information
about those vulnerable groups.
• Continue with the next 3 groups in the same manner.
• Highlight that possible solutions identified can
be linked to different Sukshema community
interventions such as family focused communication
(FFC); home based maternal and newborn care
(HBMNC) and discussion of issues pertaining to
maternal and infant death in community platforms
such as the VHSNC committee. The learning from
FFC trainings could be used as a probable solution
to minimize the gaps in communication with the
families, which is also an internal reason for a gap in
service utilization.
• Consolidate the session:
- The importance of identifying vulnerable groups,
identifying gaps, analysing the reasons for them and
identifying solutions to the problems.
- FLWs should now be able to link all the benefits of
the CDL1 Tool and CDL2 Tool and begin to analyse
the situation in the field.
FLOWCHART FOR USING THE CDL1 TOOL
AND CDL2 TOOL
Sub centre level
■-
Analysis of gaps and
problem solving
CDL2 Tool
CDL1 Tool
Monthly consolidation of targets
and achievements for ASHA self
reflection and review
First information of the
ASHA area
•
Ir
iualASI
wel
Improving the Enumeration and Tracking Process 13
TRAINING EVALUATION AND FEEDBACK FORM:
SESSION 7:
TRAINING
EVALUATION
AND FEEDBACK
KARNATAKA HEALTH PROMOTION TRUST
Training Evaluation and Feedback Form
S.No.
Objective
• To assess what affect the module had on the participants'
attitudes, knowledge and practice levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for enhancing
future effectiveness.
Methodology
(£)
Reflection
Q
2
Training methodology and activities used
3
Training skills of the facilitators
4
Logistics at the training (Food, stay and comfort)
5
Relevance and usefulness of training
1.
Tips for facilitators
Excellent
Good
Poor
j
1
List the three aspects of the training that you found most useful.
2.
The training evaluation and feedback form will assess
what affect the module had on the participants' attitudes,
knowledge and practice levels and obtain feedback on the
usefulness of the training and suggestions for enhancing
future effectiveness.
Subject
Training content and sessions
30 minutes
Training evaluation and feedback form
Name of the PHC:
1
Duration
Training Materials
Place of training:
____ Designation:
Name:
Training dates:
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
i.
2.
3What are the three most important lessons that you can take back to your work place from this training?
1.
t V-
Process
• Distribute the training evaluation and feedback form.
Go over all the areas that the participants will need to
think about while filling it in.
• Allow 20 minutes to complete it.
• Collect the training evaluation and feedback forms
from the participants.
• Before the closing ceremony begins, ask the
participants to share their feelings about the training:
encourage anyone who is keen to orally share two
positive aspects and two areas that need improvement.
• At the closing ceremony thank all the participants for
their enthusiastic participation, congratulate them and
wish them the best as they go back to their own field
areas and begin to initiate the intervention on ground.
• Thank everyone else who contributed to the training
program. This might have included administrative
staff, venue owners, facilitators, guest speakers and the
organizers.
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
2.
3.
Please list suggestions for improved facilitation in future trainings.
i
1.
2.
3.
Improving the Enumeration and Tracking Process 15
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COMMUNITY DEMAND LIST - CDL-1 (ETT-1)
I Estimated number of pregnant women:
1
9
9/10
Chandramma
Nanjundappa
A+ve
808659
26
Others
Sub Centre Name:
Village Name:
ASHAArea Name:
ASHAName:
9731918060
Code:
40
62,
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Identification details
01
02
03
S, I Womens ; Date of
No.: NaiT,e & i Registering
I Husbands; Women in
I Name/
CDL-I
Blood.
group
04
Registratian
done by
JHA:
IU*• Tl
Thayi
‘"
Gard No. &
Date
06
05
07
08
09
Phone
j Age i Caste iopi
I Gravida
Personal (P)J m
pC/ST/i< if received ,
Neicjlikjouf's j Years \ Others
card tick v if jI Para, (P)
1(G)
(NJ
10 11
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NoX
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17
16
18
19
20
Pregnancy i
ANC checki ups
tn months i Date and tyj
type of' facility -> PHC/
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■♦/days. at the time ! private/ C
Other Gcvt. FncilitMts
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(Date)
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3rd Visit: 1st ( 2nd'
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; Pregnancy
\ Number and date con iplka •
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7
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9
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12
13
14
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>ry, postnatal care and child immunizationa services till the child is 18 months old. (2)
General Instructions: (1) This toll is used to document and ensure everey pregnant woman in your area enters and stays in the MNCH care continuum through her pregnancy, deliver
section, comes from the HBMNC tool that you use for every pregnant and recently
This tool is also useful to Identify gaps in service utilization, and prioritize women for outreach. (3) The information recorded here, except most part of the childhood immunization s«
delivered woman. An example of filling the tool has been provided above.
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ANNEXURE3Guidelines for using
the CDL1 Tool
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SECTION 1: GUIDELINES TO FILL THE
IDENTIFICATION DETAILS
Column 1 - Serial number- Serial numbers have to be
used. E.g.: 1,2, 3
Column 2 - Enter the names of the woman and her
husband as also her blood group. E.g.: Chandramma,
Husband - Nanjundappa, A +ve.
Column 3 - ASHA registration- Record name of
pregnant woman, mother and children; should also
include the date of registration/entry.e.g.: 9/ 9/ 10
o
if
The CDL1 Tool developed for the ASHAs has been
broadly divided into four major sections: identification
details, ANC details, PNC details and immunization
details. The top portion of the tool consists of a column
which mentions the estimated number of pregnant
women in the area. The ASHAs should enter the number
of estimated pregnant woman after referring to the
eligible couple register (ECC). This helps the ASHA
enter all the details of the women/children in her area
of work and track them through their service cycle
ensuring that no one missed any specific across the
ANC, delivery and PNC up to the age of 18 months of
the new born. The tool filling instructions for each of the
columns are specified below:
Column 4 - Number/ Date on the Thai card- The serial
number present in the Thai card and the date when it
was issued should be note. E.g.: 808659; Date: 12/10/10
Column 5 - Telephone number- The telephone number
of the pregnant woman has to be recorded. If it is a
personal number identify it as (P) and neighbor’s phone
as (N). E.g.: 9731918060 (P)
Column 6 - Age- Record the completed age of the
woman. E.g.: 26 years
Columns 7 - Caste group- If the woman belongs to
the scheduled caste or tribe record it as SC or ST. If not
record it as “Other”
Column 8 - BPL status of the pregnant woman-If the
family has a BPL card affix a (V) mark against the place if
issued or else affix a (x)
Column 9 - Pregnant (G), Delivery (P), Abortion(A)Pregnancies (Current + Previous) have to be recorded
as Gl, G2 and so on. Previous deliveries have to be
recorded as Pl, P2, and so on. If there has been no
previous delivery mark it as P0. If there has been a
spontaneous (miscarriage) or induced abortion during
any previous pregnancy, then record it as Al, A2, and
so on. If there has been no previous instance of any
miscarriage or induced abortion, then record it as A0.
Column 10 and 11 - Number of living children Record the number of children currently alive under the
sub column ‘boy’ and ‘girl’
Column 12 - Age of the youngest child- The name and
the age in completed months of the youngest child has to
be recorded here.
SECTION 2: ANC DETAILS
Column 13 - Complications experienced during
the previous pregnancy/delivery- Affix a ("V) symbol
if there have been any complications in the previous
pregnancy/ delivery and affix a (x) mark if there have
not been any complications and it has been a normal
delivery. Commonly seen danger signs/ complications
during pregnancy and delivery are provided as head notes
in the tool.
Column 14 - Date of the Last Menstrual Period
(LMP)- Record the date of the first day of the last
menstrual period. E.g.: 18/05/2010
Column 15 - Expected delivery date or EDD- On the
basis of the LMP, the EDD can be calculated. Expected
Delivery Date is calculated by summing up date of first
day of LMP +7 days+9months. To fill this, use the EDD
table of calculation. E.g.: If the LMP is 1st of January the
corresponding EDD will be October Sth.
Column 16 - Period of pregnancy at registrationIndicate which month of pregnancy the woman was in at
the time of registration by JHA. E.g.: 3 months
Columns 17,18,19,20 - Number of ANC checkups
conducted before delivery- Record the date of the first
ANC checkup in column 17,2nd in column 18,3rd in
column 19 and if it is a complicated pregnancy, the
date of the 4th ANC check up should be recorded in
column 20.
Improving the Enumeration and Tracking Process 19
_______ J-
e v • •
Columns 21, 22, 23 - TT injection- Record the date
of the 1st TT injection in column 21, date of 2nd TT in
column 22 and the date on which BD (Booster Dose)
was taken has to be recorded in column 23.
Columns 24,25,26 - IFA tablets- Record the date and
number of IFA tablets taken in the above mentioned
columns.
Columns 27 - Complications associated with the
current pregnancy- If there are any complications
seen in the pregnant woman then affix a (>/) symbol,
otherwise affix (x) symbol. Commonly seen danger signs/
complications during pregnancy are provided as head
notes in the tool.
Columns 44 and 45 - First dose (OPV and
Pentavalent)- Record the date on which the first dose of
OPV and Pentavalent were administered
Columns 46 and 47 - Second dose (OPV and
Pentavalent)- Record the date on which the second dose
of OPV and Pentavalent were administered
Columns 48 and 49 - Third dose (OPV and
Pentavalent) - Record the date on which the third dose
of OPV and Pentavalent were administered
Column 50 - Measles (1st dose) - Record the date of
administration of the measles vaccine
SECTION 3: PNC DETAILS
Column 51 - Vitamin A- Record the date on which
Vitamin A was given
Column 28 - Record the serial number given to the
pregnant woman
Column 52 - Brain fever (1st dose) - Record the date
on which brain fever (JE) vaccine was administered
Column 29 - Date of delivery and place- Record the
date in the form date/month/year. E.g.: 12/03/2012.
Place of delivery can be PHC/other government
hospital/ private hospital. If it is not an institutional'
delivery record it as a home delivery.
Columns 53 and 54 - Booster dose (DPT, OPV) Record the date on which the booster dose injections
DPT & OPV were administered in respective columns
Column 30 - Mode of delivery- The mode can be
recorded as normal, cesarean or assisted delivery.
Column 31 - Name and sex of the baby- The name of
the child and the sex ‘M’ for male and ‘F’ for female
Column 32 - Weight of the baby- Record the weight
of the baby in grams. E.g.: If the weight of the baby is 2
kilograms, record it as 2000 grams.
Columns 33,34, 35,36,37 and 38 - PNC visits (As per
HBMNC guideline)- The visits on the days 3,7,14, 21,
28 and 42 are to be recorded with date of visit.
Columns 39,40 - Family planning- Temporary/
Permanent- affix a symbol ("V) in column 39 if the couple
are practicing any temporary method, else mark (x),
and if she/husband adopted any permanent method of
contraception (Tubectomy/ Vasectomy) affix a ("V) in
column 40, else mark (x)
SECTION 4:
Column 55 - Measles (2nd dose) - Record the date on
which the 2nd dose of measles vaccine was given
Column 56 - Brain fever (2nd dose) - Record the date
of administering the ilnd dose of the brain fever vaccine
(JE)
Columns 57 and 58 - Migration- During the follow
up period in the out migration column, record the date
on which the pregnant woman/mother left the area and
in the in migration column, record the date on which
a pregnant woman/mother has come to this area. If a
particular pregnant woman has migrated multiple times
all the dates have to be recorded.
Column 59 - Reasons for mother and child mortalityThe date along with reasons for the death of the pregnant
woman/mother or child as recognized by the ASHA has
to be recorded in this column.
IMMUNIZATION DETAILS
Column 41 - BCG- Record the date on which the BCG
vaccine was administered. E.g.: 13/2/2011
Columns 42,43-0 dose- Record the date on which
OPVO and HepatitisBO were administered.
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
iil!
isii
I ANNEXURE 4 - CDL2 Tool
COMMUNITY DEMAND LIST CDL2 TOOL
12
(To h*p ASHA tohor monthly act.on plan and to self-raflect on her own performance)
Sub Centre:
ASHA Name:
S.No
Services
1
1
Total Registration [ ],
Registration this month [ ],
Pregnant women
registration this month [ ]
2
Thai Card Issuing
(Column # 4)
3
ANC Check-up
(Column# 17,18,19 & 20)
Eligible women/
children
(Ref # of cdl-1)
■
■
PHC:
Actual Presently
Target Staying in
the village
Service
Accessed
2nd Dose - Pentavalent
(Column #47)
13
Performance
Remarks
14
1st Dose - Measles
(Column # 50)
Vit A
(Column # 51)
JE
(Column # 52)
15
i (Column#21,22 &23)
Booster Dose - DPT
(Column # 53)
Booster Dose - OPV
(Column # 53)
I FA
(Column # 24,25 & 26)
l EDD
3rd Dose - OPV
(Column # 48)
3rd Dose - Pentavalent
(Column # 49)
(% to Actual
target)
4
5
2nd Dose - OPV
(Column # 46)
2nd Dose - Measles
(Column # 55)
List of those who
received 100/200
IFA tablets
2nd Dose - JE
(Column # 56)
6
(Column #15)
7
8
PNC Services
(Column # 33,34, 35, 36,
37 & 38)
Measles - 2nd Dose
(Column # 55)
16
List of those who
completed all
PNC visits
Family Planning
j (Column # 39 &40)
9
Family Planning (Those
who are not listed in
CDL1) (Column # 39)
10
BCG
(Column #41)
ASHA's performance in
providing services to all
(Total numbers)
JHA Signature
ASHA Signature
0 Dose - OPV
(Column # 42)
0 Dose - Hep B
; (Column # 43)
i....................
11
i 1 st Dose - OPV
(Column # 42)
1 st Dose - Pentavalent
(Column # 43)
22 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Improving the Enumeration and Tracking Process 23
■«
ANNEXURE5Definitions of Indicators
for using CDL2 Tool
. INDICATOR
TARGET
ACHIEVEMENT
ANC registration
This is a constant number every month -Esti
number of pregnant women as per the recei
# of pregnant women issued Thayi card
in the reporting month, based on the
date of registration in CDL1 Tool
TT injection
# of pregnant women who hav
TT injection so far irrespective
CNA/12, rounded off to the nearest integer
pregnancy PLUS
# of pregnant women who received
TT injections (either TT1 or TT2 or TT
Bolster) in the reporting month
a
IFA100
if of pregnant women in their 4th to 9th i
of pregnancy who have so far received <
tablets PLUS
# of severely anaemic pregnant women
ANC check-up
# of pregnant women in their 3rd to 6th month of
pregnancy who did not receive any ANC check-up
from a medical doctor (either in a government or a
private facility) PLUS
# of pregnant women in their 7th to Sth month of
pregnancy who received <2 ANC check-ups from a
# of pregnant women who reached a
cumulative of 100/200 I FA tablets in the
month
<2001FA tablets
# of pregnant women who received
ANC check-up from a medical doctor
(either in a government or a private
facility) in the reporting month
medical doctor (either in a government or a private
facility) PLUS
ii of pregnant women in their 9th month of
pregnancy who received <3 ANC check-ups from a
medical doctor (either in a government or a private
facility)
Delivery
# of pregnant women who are due for delivery in
the reporting month, based on the EDD
This has two parts:
1. # of women who delivered at home
in the reporting month
2. # of women who delivered in a
facility (government or private) in the
reporting month
PNC visits
# of delivered women who have received <6 PNC
visits (based on PNC visit dates) within 42 days of
BCG
# of children age <12 months who did not receive a
BCG vaccination
# of children age <12 months who did
# of children under age 15 days who have not
received OPV birth dose PLUS
# of children age 45 days and above who have not
received the 1st dose of OPV PLUS
# of children age 75 days and above who have not
received the 2nd dose of OPV PLUS
# of children age 105 days and above who have not
received the 3rd dose of OPV
# of children age <12 months given
OPV vaccination in the reporting month
# of children within 24 hours after birth who have not
received Hep B birth dose PLUS
# of children age 45 days and above who have not
received the 1st dose of Hep B
# of children age 75 days and above who have not
received the 2nd dose of Hep B
# of children age 105 days and above who have not
received the 3rd dose of Hep B
# of children age <12 given HepB
vaccination in the reporting month
DPT
[Can be administered
till attainment of two
years of age]
# of children age 45 days and above who have not
received the 1st dose of DPT
# of children age 75 days and above who have not
received the 2nd dose of DPT
# of children age 105 days and above who have not
received the 3rd dose of DPT
# of children age <12 months given
Pentavalent vaccine
# of children age 45 days and above who have not
received any dose of pentavalent vaccine and any
dose of Hep B,DPT and OPV
# of children age <12 months given
pentavalent vaccine in the reporting
H of children age 9 months and above who have not
received measles vaccine
# of children age <12 months given
measles vaccination in the reporting
HepB
[Can be administered
only during the
first year of life and
should only be given
along with DPT; thus
if a child age <12
months has already
received three doses
of DPT but missed
any dose of Hep B,
the child cannot be
administered Hep B
and would move out
of target]
# of delivered women who received 6+
PNC visits in the reporting month
DPT vaccination in the reporting month
delivery (based on date of delivery)
OPV
(can be given anytime
within 5 years of age)
not receive a BCG vaccination
Measles
month
month
Family planning
Local resident women listed in the CDL1 Tool who
are not currently using any family planning methods
# of local resident women who are
currently using any family planning
method, separately for permanent and
temporary methods
24 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
Improving the Enumeration and Tracking Process 25
2.2- Eligible women/ children- this refers to the serial
numbers of women who have received Thai card. It is a
cumulative count.
ANNEXURE6
Demonstration of
CDL2 Tool
2.3- Expected Beneficiary- refers to the total numbers
of women to be issued Thai card in the current month.
2.4- Presently staying in the village- In this column
the ASHA record this number- Of the total expected
beneficiaries, how many are currently residing in the
village/ ASHA area
Below is a brief demonstration of filling in the CDL2
Tool. This exercise is focused on the first two indicators,
which have numbers inserted as per CDL1 Tool. This
will help the ASHA to prepare her monthly action plan
and to self-reflect on her own performance.
2.5- Service Accessed- In this column the ASHA will
record this number- Of the numbers staying in the
village, for how many she could manage a Thai card. This
indicates the achievement.
COMMUNITY DEMAND LIST CDL2 TOOL
2.6- Performance- This % refers to:
The number recorded under the service accessed
column
X 100
Month:
|
(To help ASHA to preoare her monthly action plan and to self-reflect on her own performance)
Services
,
i
i Total Registration [ ],
i Registration this month [ ],
I Pregnant women
i registration this month [ ]
2
| Thai Card Issuing
2.7- The remarks column allows for the ASHA to record
reasons for not being able to achieve the target.
Indicator number 16 which is the last in CDL2, is a
consolidation of the targets and achievements of all
the previous 15 indicators. The ASHA adds up the
total numbers under the three columns- Expected
Beneficiaries, Presently Staying in the village and Service
accessed based on which she then calculates her %
performance. This indicator is used by the ASHA to
carry out a self reflection and self assessment of her
performance during the month. She does this every 21st
during the ASHA meeting. Below this the concerned
ASHA should affix her signature and get the signatures
of the ASHA facilitator and Junior Female health
Assistant as well every month.
PHC:
Sub Centre:
ASHA Name:
:S.No
The number recorded under presently staying in the
ASHA area
Eligible
children
(Ref# of cdl-1)
Actual
Target
2
3
.’resently
Pn
Staying in
the village
Service
Accessed
4
5
Performance
Remarks
{% to Actual
target)
6
7
ANNEXURE 7 Gap Analysis
Exercise
I
|
I (Column # 4)
1.1- Services- This section indicates which information
the ASHA needs to derive from the CDL1.
1.2- Eligible women/ childrenTotal registration- In this column the ASHA has to
record the serial numbers of all the women registered so
far. This is a cumulative count.
Registration this month- this refers to the serial numbers
of pregnant women/mothers registered in the current
month alone. These are new entries.
Pregnant women registration this month- this refers to
the serial numbers of the new pregnant women the ASHA
herself registered in her area in the current month.
many are currently residing in the ASHA area
Pregnant women
and newborn in
the vulnerable list
Gaps Identified
1.5- Service Accessed- In this column the ASHA will
record this number- Of the numbers staying in the
village, how many she was able to give or link to services.
This indicates the achievement.
Solutions
identified
Reasons for gaps
; Service seekers*
I (External)
Service providers**
(Internal)
■■■I
1.6- Performance- This % refers to:
The number recorded under the service accessed
column
X 100
The number recorded under presently staying in the
ASHA area
1.3-Actual target refers to the total numbers of those that
require services and not the serial numbers of women.
1.7- The remarks column allows for the ASHA to record
reasons for not being able to achieve the target.
Example 2- Thai Card issuing
1.4- Presently staying in the ASHA area- In this column
the ASHA record this number- Of the total target, how
2.1- Refer to CDL1, column # 4 for this indicator- This
refers to the women who have been issued Thai card
* Service seekers: Mother and newborn, ** Service providers: Health system and the health workers.
Improving the Enumeration and Tracking Process 27
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• n • •
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Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
HOME BASED
MATERNAL AND
NEWBORN CARE
Community Level Interventions for
Improving Maternal, Neonatal and Child
ACKNOWLEDGEMENTS
Health Training Tool Kit: Home Based
Maternal and Newborn Care, is the sixth
module of the tool kit in a series of seven
on enhancing community engagement for
improving outreach, shaping demand and
The following institutions and individuals contributed
to the idea, design, writing and editing of this tool kit:
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
strengthening accountability to improve
maternal, neonatal and child health
outcomes in Karnataka.
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
Dr. Krishnamurthy, UOM
Mr. Mohan H.L, UOM
Dr. BM Ramesh, UOM
Mr. Nagaraj Ramaiah, KHPT
Mr. Manjunath Dodawad, KHPT
Dr. Navya R, KHPT
Ms. Prathibha, KHPT
Mr. Suresh Garagatti, KHPT
Dr. Ravi Kadagavi, KHPT
Mr. Somashekar Hawaldar, KHPT
Dr. Suresh Chitrapu, KHPT
Mr. Raghavendra Kamati, KHPT
Ms. Geetha, JHA, Bagalkot
Ms. Savitha, ASHA Mentor, Bagalkot
Ms. Sheela, ASHA, Koppal
Ms. Usha, ASHA, Koppal
Ms, Basamma, ASHA, Bagalkot
Ms. Narasingamma, AWW, Koppal
HOME BASED
MATERNAL AND
NEWBORN CARE
The National Rural Health Mission of Karnataka
State, the Department of Health and Family Welfare,
Karnataka State, Department of Women and Child,
Karnataka State supported this initiative.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & Sth Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91-80-40400200
Fax: 91-80-40400300
www.khpt.org
The following officials from the Department of Health
helped us in our efforts:
Mission Director, NRHM
DHO of Koppal and Bagalkot districts
RCHO of Koppal and Bagalkot districts
DPMO of Koppal and Bagalkot districts
Deputy Director, Women and Child Department of
Koppal and Bagalkot
All the taluk coordinators, resource persons, medical
officers and all the front line health workers in Koppal
and Bagalkot Districts contributed to the process of
developing, piloting and rolling out the Tool Kit.
Year of Publication: 2014
Copyright: KHPT
THE EDITORIAL TEAM:
Mr. H.L. Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Ms. Prathibha Rai, KHPT
Ms. Dorothy L Southern, KHPT Consultant
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
The photographs are by KV Balasubramanya.
They have been used in the module with consent
from the community.
^j^^uksherna
Improved Maternal, Newborn & Child Health
ip&i wn ftsn
PREFACE
The Community Level Interventions for Improving Maternal, Neonatal and Child
Health Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Health Workers
Module 5: Improving the Enumeration and Tracking Process
Module 6: Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 6: Home Based Maternal and Newborn Care is a training module
for Accredited Social Health Activists (ASHAs) developed to enhance their
communication skills and quality of homes visits. Once the ASHAs complete the
enumeration and tracking of their area, they have the responsibility to ensure that
all services reach the beneficiaries. It is the ASHAs' prerogative to reach out to the
mother and child through home visits to deliver information, create awareness,
identify symptoms of risk early and make timely referrals. In this context the
quality of home visits conducted by the ASHAs need to result in bridging the
information gap to a greater extent and bring about the expected results
mentioned above. This module aims to specifically improve the capacities and
the skills of the ASHA to conduct effective home visits by using the Home Based
Maternal Newborn Care (HBMNC) Tool.
CONTENTS
ACRONYMS
6
Getting Started: The Doorway to Successful Training
7
SESSIONS
Session 1: Maternal, infant and child mortality
8
Session 2: Stages of service delivery
9
Session 3: Front line health workers: providing MNCH continuum of care services
12
Session 4: The HBMNC Tool: providing quality MNCH continuum of care services
14
Session 5: Using the HBMNC Tool - Section 1 Identification
15
Session 6: Providing ANC services
16
Session 7: Using the HBMNC Tool - Section 2 ANC
18
Session 8: Providing Intra-natal (Delivery) care services
19
Session 9: Using the HBMNC Tool - Section 3 Delivery
20
Session 10: Providing PNC services
20
Session 11: Using the HBMNC Tool - Section 4 PNC
22
Session 12: PNC home Visits: Health education and counselling
22
Session 13: Introducing IEC materials
25
Session 14: Practical use of the HBMNC Tool
26
Session 15: Training evaluation and feedback
28
ANNEXURES
Annexure 1: HBMNC Tool
30
Annexure 2: HBMNC Tool filling guidelines
38
Annexure 3: ASHA Reminder Cards
47
_- -
■
ACRONYMS
ANC
ARI
ARS
ASHA
AWW
BCC
BP
BPL
CBO
CDL
CMR
DOH
EDD
FLW
FP
FRU
GoK
HBMNC
IEC
I FA
IMR
I PC
JHA
JSY
KHPT
MDG
MMR
MNCH
NGO
NRHM
PHC
PNC
PRI
RP
SBA
SC
SC/ ST
SCM
TBA
TT
VHW
VHSNC
6
Ante Natal Care
Acute Respiratory Infection
Arogya Raksha Samitis
Accredited Social Health Activist
Anganwadi Worker
Behaviour Change Communication
Blood Pressure
Below Poverty Line
Community Based Organization
Community Demand List (CDL1) Tool
Child mortality rate
Department of Health
Expected Date of Delivery
Frontline Health Worker
Family Planning
First Response Unit
Government of Karnataka
Home Based Maternal Newborn Care
Information, Education, Communication
Iron and Folic Acid
Infant Mortality Rate
Inter Personal Communication
Junior Female Health Assistant
Janani Suraksha Yojana
Karnataka Health Promotion Trust
UN Millennium Development Goals
Maternal Mortality Rate
Maternal, Newborn and Child Health
Non-Government Organization
National Rural Health Mission
Primary Health Centre
Post-natal Care
Panchayat Raj Institution
Resource Person
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Supportive Community Monitoring
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health Worker
Village Health and Sanitation Nutrition Committee
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
I
---- . . ...
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JB
I
GETTING STARTED
’ihe Doorway Io Successful Training in
Part 11 of Module 1 should always be
used to start a training workshop: initially
if covering all modules al one lime, or
as a refresher if modules are scheduled
over a period of lime. Ihe Doorway to
Successful Training contains a detailed
plan of sessions that sets the stage for the
workshop activities and logistics, covering
welcome, introductions, objectives, hopes
and fears, and ground rules.
A•
A A 4
A
W&
...
INFORMATION GUIDE FOR SESSION 1
SESSION 1:
MATERNAL, INFANT
AND
CHILD MORTALITY
Process
Objective
• To engage ASHAs in a discussion around the core
issue of maternal, infant and child mortality and
the root causes.
Methodology
Duration
Q & A and discussion
30 minutes
Training Materials
PPP, markers and brown sheets/ chart paper and copies
of Information Guide for Session 1
Tips for facilitators
Encourage the participants to think critically about
the issues and have them cite local examples from
the field to increase their understanding.
• Set the scene by sharing the current MNCH
situation with respect to maternal, new bom and
the infant mortality in India and within the state/
region. Share data and other facts about the trends
seen in MNCH.
• Ask participants the following questions:
- What is abortion?
- What is still birth?
- What is maternal mortahty?
- What is maternal mortality ratio (MMR)?
- What is infant mortality?
- What is infant mortality rate (IMR)?
- What is child mortality?
- What is child mortality rate (CMR)?
• Use the pre-prepared chart ‘Information Guide
for Session 1’ to correct definitions and provide
explanation for the above questions.
• Ask participants probing questions on the causes
for maternal, infant and the child mortality
to understand at what stages there are higher
occurrences of mortality. For example, delivery at
home, during shifting the woman to the hospital,
during delivery and within 42 days post-delivery.
• Use PPP/ posters to explain the medical and social
causes for maternal, infant and child mortality.
• Consolidate the session:
- Medical definitions of maternal, infant and child
mortaEty are not sufficient.
- Unless the root causes of mortality and the
circumstances that pose high risk to women and
children are understood, FLWs will not be able
to effectively address the problem of MMR, IMR
and CMR.
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ing
it
• Abortion: The termination of pregnancy by the
removal or expulsion from the uterus of a foetus or
embryo prior to viabilityi.e. < 2o weeks of pregnancy
• Still birth: Death of the foetus more than 20 weeks of
pregnancy or death during the delivery, birth of life
less foetus weighing 1000 grams and measuring over
35 cms.
• Maternal Mortality: Death of the mother during
pregnancy/ during delivery/ during abortion/
or within 42 days of delivery, because of the
complication during pregnancy and its management
and NOT due to accident, trauma or any other
reasons
• Maternal Mortality Ratio: Number of death of
mothers per 100000 live births in a specific area, in a
year
. Infant Mortality: Ihe death of child within 28 days
from the birth
• Infant Mortality Rate: Number of child deaths per
lOOOjive births in a year
• Child Mortality: The death of child within a year of
birth
• Child Mortality Rate: The number of death of the
child within a year of birth per 1000 live births
CAUSES AND INSTANCES OF RISK OF
MATERNAL, INFANT AND CHILD MORTALITY
• Social causes: Attitudes in the society with respect
to the womans status at home, religious, caste and
creed based discrimination, the systems and customs
followed at home, decision making/inilucncing
authority regarding home based care and their
information levds/beliefs, the education level of
the family members. These are indirect causes that
determine whether or not healthy practices are
followed for the benefit of the woman and child.
• Service delivery systemic causes: Distance to
hospital, shortage of medical staff and facilities,
attitude and behaviour of medical staff, delay in
service delivery.
• Medical causes: Causes for maternal mortality
include excessive bleeding, infection, high blood
pressure, repeated and unsafe abortions.
» Causes for child mortality include infection.
Pneumonia, pre mature delivery, low body weight.
• Please note that there may be several other causes
apart from the ones mentioned above.
• Most of ffie maternal and infant deaths occur during
deliver)' and within 2 hours of delivery.
Objective
• To help ASHAs gain clarity about specific services
available at different stages of the MNCH continuum
of care.
Methodology
Group work and discussion
e
Duration
1 hour
Training Materials
Markers and brown sheets/ chart paper and copies of
Information Guide for Session2
Tips for facilitators
Encourage participants to cover all the services, even
those which might seem unimportant. Services could
be available at multiple facilities. In that case, list all the
probable facilities/ individuals from where services can
be accessed.
Desiaii, . tanning mtd Implementation of the Suxshema Project
9
Process
■
'
• Normal delivery with the use of
• In the MN CH continuum of care, ask them which
stages they are responsible for.
• Note their responses on a flip chart
• Divide the participants into three groups and
distribute chart paper and markers to each group.
• Assign group 1 to report on ANC services; group 2 to
report on delivery services; and group 3 to report on
PNC services.
• Ask them to:
- List all the services that need to be given to the
women/ new born under their groups stage
- Identify where/ which facilities these services could
be accessed.
• Allow 20 minutes to complete the exercise, then ask
a representative from each group to take 5 minutes to
share their responses.
• Ask other groups to contribute any other key
information.
• Continue with the next 2 groups in the same manner.
• Use the pre-prepared chart ‘Information Guide for
Session 2’ to wrap-up all the presentations.
• Consolidate the session:
- Understanding the stages of service delivery stages
and the available services at those stages will ensure
the FLW is able to perform effectively and efficiently.
INFORMATION GUIDE FOR SESSION 2
partograph
• Active management of third stage of
labour
• Infection prevention
• Identification of danger signs and
appropriate higher care referrals
• Pre — referral management for
obstetric emergencies, e.g
eclampsia, PPH, shock
• Assured referral linkages with higher
All in Level 2 and
All in Level 1 and
Availability of following services
round the clock
• Availability of following services
round the clock
• Management of obstructed
labour
• Surgical intervention like
• Episiotomy and suturing cervical
tear
• Assisted vaginal deliveries like
outlet forceps, vacuum
• Stabilisation of patients with
Caesarean section
• Comprehensive management
of all obstetric emergencies,
e.g. PIH/Eclampsia, Sepsis, PPH
retained placenta, shock etc.
• In-house blood bank/blood
obstetric emergencies, e.g.
eclampsia. PPH, sepsis, shock
• Referral linkages with hither
facilities
• Essential new bom care as in
facilities
• Essential new bom care will include:
• Neonatal resuscitation
• Warmth
• Infection prevention
• Initiation of breast feeding within an
hour of birth and exclusive breast
feeding there after
• Screening for congenital anomalies
• Weighing of newborns
storage centre
• Referral linkages with higher
facilities including medical
colleges
• Essential new bom care as in
level 2 +
• Care of LBW newborns
<1800gm
level 1 +
• Antenatal Corticosteroids to
the mother in case of pre-term
babies to prevent Respiratory
Distress Syndrome (RDS)
• Immediate care of LBW
newborns (> 1 BOOgm)
ANTENATAL CARE
LEVEL 1
|
LEVEL 2
LEVEL 3
Instftutipnal
Skilled Birth Attendant (SBA) Level
Institutional (Basic Levety
Delivery by SBAs (Sub centre, PHCs not
functioning as 24x7 and home deliveries
conducted by SBA
PHC - Basic Obstetric and
Neonatal care (24X7 PHCs, CHCs
other than FRUs)
FRU - comprehensive
Obstetric and Neonatal care (
DH,SDH,RH,CEmONC, selected
CHCs)
All services menuoneo
mentioned uni
under in
rtii
Level 1 and the following:
All services mentioned under in
j
'
I
• Blood grouping & Rh typing.
Wet mount(saline/KOH), RPR/
• Blood cross matching +
management of severe anaemia
.'
j
VDRL
• Management and provision of
all emergency obstetric and
new born care for complications
• Management of complications in
pregnancy referred from Levels
■_
J
POSTNATAL AND NEWBORN CARE
3
<LEVEL I
ANC session should indude:
• Registration (within 1 st trimester)
• Physical examination +
weight+BP-r-abdominal examination
• Identification of danger signs and
appropriate higher care referrals
• Ensuring consumption of at least 100
IFA tablets (for all pregnant women)
200 (for anaemic women). Severe
anaemia needs referral
• Essential lab investigations (HB%,
urine for albumin/sugar, pregnancy
test)
• TT immunisationftwo doses at interval
Delivery by SBAs (Sub centre, PHCs not
functioning as 24x7 and home deliveries
conducted by SBA
FRU - comprehensive
Obstetric and Neonatal care (
DH,SDH,RH,CEmONC, selected
PHC - Basic Obstetric and
Neonatal care (24X7 PHCs, CHCs
other than FRUs)
CHCs)
Level 1 and the following:
1 and 2
other than these requiring blood
transfusion or surgery
• Linkages with nearest ICTC/
PPTCT centre for voluntary
counselling and testing for HIV
and PPTCT services ,
of one month)
• Counselling on nutrition, birth
preparedness, safe abortion and
• Minimum 6 hours of stay post delivery
• Counselling for feeding, nutrition,
family planning, hygiene,
immunisation and PN check-up
• Home visits on 3rd, 7th and 42nd
day, both for mother and baby are
needed. Additional visits are needed
for the new born on day 14, 21 and
28. further visits may be necessary for
LBW and sick newborns
• Timely identification of danger signs
and complications and referral of
mother and baby
i
_
All mentioned in Level 2 and the
All mentioned in Level 1 and the
following:
following:
• 48 hours of stay post delivery
and all the postnatal services
for zero and third day to mother
and baby
• Timely referral for woman with
postnatal complications
• Stabilisation of
mother will i postnatal
• Clinical management of all
maternal emergencies such
as PPH, Puerperal Sepsis,
Eclampsia, Breast Abscess,
post surgical complication,
shock and any other postnatal
complications such as RH
incompatibility etc.colleges
emergencies,e g. PPH,sepsis,
shock, retained placenta
• Referral linkages with higher
facilities
New born care
New born care as in Level 2 and
the following:
• In district hospitals through Sick
institutional delivery)
• Assured referral linkages for
complicated pregnancies and
deliveries
INTRANATAL CARE
■1. LEVELS
LEVEL 1
!
LEVEL 2
SBA Level
•
Institutional (Basic Levels
Institutional
PHC - Basic Obstetric and
Neonatal care (24X7 PHCs, CHCs
other than FRUs)
FRU - comprehensive Obstetric
and Neonatal care (DH, SDH, RH,
CEmONC, selected CHCs)
- ------Delivery by SBAs (Sub centre, PHCs not
functioning as 24x7 and home deliveries
conducted by SBA
LEVEL-rw
LteVl£t4
tpstity^onal
tastitutiohal
LEVELS
*' InstiMlouai (Bask Level) ' "
10 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• Warmth
• Hygiene and cord care
• Identification, management and
New born care as in Level 1 and
the following:
Newborn Care Unit (SNCU)
• Management of complications
• Care of LBW newborns
referral of sick neonates, low birth
weight(LBW) and pre-term newborns
• Referral linkages for management of
complications
• Care of LBW newborns <2500gm
• Zero day immunisation OPV.BCG,
Hepatitis B
• Stabilisation of complications
and referral
• Care of LBW newborns
> 1800gm
• Referral services for newborns
<1800 gm and other newborn
complications
• Management of Sepsis
< 1800 gm
• Establish referral linkages with
higher facilities
i
i
Design, Planning and Implementation of the Sukshema Project 11
———
INFORMATION GUIDE FOR SESSION 3
SESSIONS:
FRONTLINE HEALTH WORKERS:
PROVIDING MNCH CONTINUUM
OF CARE SERVICES
The roles and responsibilities of the three
frontline health workers in HBMNC are as
follows:
Objective
Process
• Divide the participants into three groups and distribute chart paper and
markers to each group.
• Ask the participants who are some of the most important FLWs related to
the MNCH continuum of care?
• Note their responses on a flip chart.
• Assign group 1 to report on ASHAs; group 2 to report on JHAs; and group
3 to report on AWWs.
• Ask them to:
- Discuss the respective roles and responsibilities in providing MNCH
continuum of care services.
• Allow 20 minutes to complete the exercise, then ask a representative from
each group to take 5 minutes to share their responses.
• Ask other groups to contribute any other key information.
• Continue with the next 2 groups in the same manner.
• Use the pre-prepared chart ‘Information Guide for Session 3’ to wrap-up
all the presentations.
;
;
!
;
;
•
:
;
• To clarify the roles and
responsibilities of frontline
health workers (FLWs) such
as Accredited Social Health
Activist (ASHA), Junior Female
Health Assistant (JHA), and
Anganwadi Worker (AWW) in
providing MNCH continuum of
;
I
;
■
I
care services.
• To help participants know
the importance of other FLW
roles and responsibilities in
improving MNCH services.
•
Methodology
Group discussion
Q
Duration
1 hour
• Consolidate the session:
- Clarity of roles is essential to avoid confusion or overlapping of service
delivery on the ground.
- Clearly understanding the roles and responsibility of other FLWs is
crucial for mutual support in the field.
- There may be common responsibilities among the three. Let them know
that some commonalities/overlaps are fine as long as there is shared
work and cooperation to deliver services.
Training Materials
!
;
■
rty L
rterv
ns fo
rovir
term
onat
I Chi
Mi:
ning
Markers and brown sheets/ chart
paper and copies of Information
Guide for Session 3
Tips for facilitators
;
I
I
;
■
I
;
■
I
Cor
• Accredited Social Health Activist (ASHA):
1. Conduct home visits and enlist expected
pregnancies and children up to the age of 5.
2. Meet a pregnant woman at least 3 times
and conduct necessary health education or
counselling sessions.
3. Offer support to conduct the pregnant
womens meeting.
4. Take the pregnant woman to the hospital
for delivery and those with possible risks to
higher centres well ahead of the due date.
5. Conduct post-delivery follow up home
visits and impart needed health messages.
6. Identify the danger signs among the
pregnant, noising mother and newborns,
providing first aid and referring to higher
care
7. Provide care for the newborn
immunisation within 2 years.
Although the HBMNC Tool has
been designed for use by the
ASHA, as part of Sushema's
current training strategy all
three FLWs are involved in the
training. Understanding all of their
responsibilities is important to
ensure mutual support and role
clarity.
Kit
juniur Female Health Assistant (JHA):
1. Enrolment of the pregnant women
2. Administration of TT injection and
measuring BP of the pregnant woman,
checking the weight of the child after
delivery and administration of FS tablets
after 5 months of delivery.
3. Filling of “Thayi” card during die
registration of the woman.
4. Imparting education on nutritious food,
hygiene and institutional delivery to the
woman
5. Provide Information to the pregnant
woman on scanning and its benefits
6. For the 1st and 2nd delivery, provide
information about the government schemes
available like JSY, Prasoethi Araike and
Madilu Kit
7. Explain the immunisation process to new
mothers
8. Refer pregnant women with complications
to higher care centres.
9. Educate the family about home based care
needed for the new born baby especially
with low birth weight.
10. Provide information to nursing mothers
about precautions to be taken to avoid
infection.
11. Collection of blood samples for testing if
the pregnant woman or the nursing mother
runs fever
12. Inform the women about the side effects
of immunisation, importance of breast
feeding, maternal and newborn care at
home, permanent and temporary family
planning options
13. Conduct deliveries in case of emergencies in
the sub centres
14. Referral services for higher care
15. Immunisation
16. Conduct home visits with the ASHA and
examining the formats filled by the ASHA
17. Provide guidance and information to the
ASHA on HBMNC
18. Train the ASHA at the PHC level
• Anganwadi worker: (AWW)
1. Conduct the mother’s meeting and provide
health education
2. Conduct home visit to pregnant, nursing
mothers & children between the age group
of 6 months to 3 years. The purpose of this
visit is to counsel women and families on
the issues of nutrition.
3.. Keep track of the children's weight and send
the graded children to higher centres
4. Identify Grade children (malnutrition cases)
and enrol for Bhagyalakshmi scheme (only
for the B PL card holders)
5. Identify healthy children and conduct baby
shows
6. Conduct the Balavikasa Samithi meetings
7. Encourage and motivate people to seek
institutional delivery and adopt family
planning methods
8. Identify the children with sickness and
refer for higher treatment under the “Bala
Sanjeevini" program
9. conduct Nutrition camps and distribute
nuliiiious food fot lire children between
the age groups of 6 months to 3 years and
pregnant women and nursing mothers
10. Mobilize pregnant women for
inununisation camps
11. Register the child post delivery
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SESSION 4:
THE HBMNC TOOL: PROVIDING
QUALITY MNCH CONTINUUM
OF CARE SERVICES
Process
• Divide participants into four groups to prepare role plays.
- Group 1 to enact the 1st home visit with pregnant woman
- Group 2 to enact the 2nd home visit with high risk pregnant woman
- Group 3 to enact the 3rd home visit with healthy baby bom at PHC
- Group 4 to enact the 4th home visit with sick baby born at home
• Ask them to first discuss key aspects of their home visits and to
emphasise key messages that need to be given during the home visit
• Allow 15 minutes to prepare their role play.
• After each group has performed their role play, ask participants to
recall different messages that were given. Ask spectators if there were
components that the ASHA missed out during the home visit, for
example, identifying danger signs, or counselling, etc.
• After all groups have performed, ask how home based care can be given
without missing any components and providing all messages.
• Note their responses on a flip chart.
• Tell them that the HBMNC Tool attempts to help the ASHA make her
home visits very specific and guide her through important indicators to
look for during the home visits.
• Distribute copies of the HBMNC Tool to all the participants (Annexure
1). Tell them to keep their copy of the HBMNC Tool available for use
during all the sessions of Module 6.
• Briefly go over the key sections of the HBMNC Tool and some of the
important indicators.
• Tell participants that in future sessions they will learn more details of the
HBMNC Tool.
■I
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?
7
*
-
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J
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t; *
;
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.(^^ Objective
4^ Objective
• To enable ASHAs to see the
gaps in home visits in the field
• To help ASHAs see the relevance
of the HBMNC Tool in providing
quality HBMNC
• To help participants understand
the importance of timely
identification of pregnant
women and nursing mothers.
• To introduce participants to
Section 1 of the HBMNC Tool.
Methodology
Role play and discussion
Methodology
Group discussion
4^ Duration
1 hour
Duration
1 hour
Training Materials
Training Materials
Markers and brown sheets/ chart
paper, and copies of the HBMNC
Tool (Annexure 1)
Markers and brown sheets/ chart
paper, and copies of the HBMNC
Tool (Annexure 1)
Tips for facilitators
Tips for facilitators
The role plays will help the
participants to explore all the
necessary components that must
be included in a home visit and
ways to improve the content
and communication skills will be
explored together.
Before this session, thoroughly
review Annexure 1. The participants
will have the opportunity to have
guided hands-on experience to fill
in Section 1 of the HBMNC Tool so
be prepared for detailed questions
about where to get the information
and where to put the information.
SESSION 5:
USING THE HBMNC TOOLSECTION 1 IDENTIFICATION
4J Process
• Ask participants how to identify eligible pregnant women and nursing
mothers.
• Note their responses on a flip chart.
• Ask them what is the basic information that they need to provide
comprehensive ANC services?
• Note their responses on a flip chart.
• Now tell them to look at Section 1 of the HBMNC Tool.
• Read through each of the components in Section 1 aloud and explain
how and why this section is important. Clarify any doubts that the
participants may have.
• Tell each participant to use an example of the most recent home visit
they conducted. They can refer to their registers to obtain the woman’s
details if they cannot recollect it on their own.
• Allow 10 minutes to fill in Section 1 of the HBMNC Tool using that
information.
• Verify if all the entries are correctly filled in by individually looking at
formats randomly among the group.
• Select one filled format randomly from the group and discuss if it has
been filled in correctly by going over each of the indicators in plenary.
• Ask if there are any questions about how to fill in Section 1.
• Consolidate the session:
- The eliciting and recording of basic information of the woman during a
home visits is crucial.
• Consolidate the session:
- Home visits lack direction and critical messages are often forgotten if
the ASHAs lacks a job aid or tool to help them remember everything
that need to do or say during a home visit.
- A job aid or tool can make home visits more effective.
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Design, Planning and Implementation of the Sukshema Project 15
INFORMATION GUIDE FOR SESSION 6
Maternal mortality occurs during pregnancy, delivery
and post-delivery due to excessive bleeding, infection/
sepsis, obstructed delivery, BP, unsafe abortions and also
due to anaemia, heart ailments, malaria and hepatitis.
Ihe infant mortality mainly occurs due to Pneumonia/
infection, breathing difficulty, and pre mature delivery.
SESSION 6:
PROVIDING
ANC SERVICES
But by providing correct health education/cuunselling
on the necessary care to be availed during the MNCH
continuum of car, paying special attention to any danger
signs and taking needed actions, most of the problems
above can be prevented.
© Objective
Process
• To help participants identify ANC services that can be
accessed during pregnancy to delivery.
• To understand the importance of identifying pregnant
women with danger signs and possible complications
and referring them to the next level of care.
• Divide the participants into four groups and
distribute chart paper and markers to each group.
• Ask them to answer these questions:
- What are components of care that needs to be
provided to pregnant woman?
- What are the symptoms of a complicated pregnancy?
- What is the impact on the woman and child if these
symptoms are not identified in time?
- What are the danger signs that are observed during
pregnancy?
• What is the role of the ASHA in providing ANC
services?
• Allow 20 minutes for discussion, and then ask a
representative from each group to take 5 minutes to
share their responses.
• Ask other groups to share any other key information.
• Continue with the next 3 groups in the same manner.
• Use PPP and the pre-prepared chart ‘Information
Guide for Session 6’ to wrap-up all the presentations
and provide a complete picture of ANC services to
the participants.
Methodology
PPP and group discussion
Duration
1 hour
Training Materials
Markers and brown sheets/ chart paper and copies of
Information Guide for Session 6
Tips for facilitators
Medical terminology may not be always understood
by the participants so clarify the difference between
terms such as complicated pregnancy and danger signs
during pregnancy. Use suitable examples and local
alternative words.
• Consolidate the session:
- Continuous ANC services provided by the ASHA
from pregnancy to delivery is crucial.
i Cc
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Inter
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>rovi
sten
sons
dCh
•ahh
tinini
J Kit
Necessary cure to be given to pregnant women in the
ANC period covers the following:
• ANC registration (Thayi card)
• Information on ANC testing facility at PHC or higher
centre
» Providing TT immunisation
• Pre delivery/ birth preparation
• Testing of blood and urine
• Weight, abdominal resting , foetal heart beat
examination
• Information on nutrition
• Supplements of iron and folic acid tablets
• Promotion of breast feeding and importance of
feeding colostrums immediately after birth
• Information on personal hygiene
• HIV testing and counselling on family planning
• Information on VHND and mothers meeting
• Information on birth gap
• Information on facilities provided by the government
Information on a complicated pregnancy and impact
of unidentified symptoms:
■ Anaemic - HB lower than 7gm
• First pregnancy within 18 years of age and after 30
years of age
• First time pregnancy and the dwarf (lesser than
HOcins)- Short primi gravida (First pregnancy and
height <4’10’*
• Displacement of baby in the womb
• Bleeding during pregnancy
• Undergone more than 3 deliveries
• Swelling in the face/hands, seizures. High blood
pressure during/because of pregnancy
• Pre-Eclampsia/Eclampsia
• RH incompatibility
• Previous surgery use of lUD/prolonged delivery/still
birth/ death of foetus m womb/ artificial removal oi
placenta/PPH
All the above components are very crucial and even
a slight negligence can lead to death of the mother or
child. In such cases, immediate further investigation in
higher centres is needed.
Information on the danger signs in pregnancy:
• Fever
• Head ache and blurred vision
• Excessive vomiting
• Fits! seizures / Epilepsy7
• Difficulty in urination or less urine output
• Pain in the stomach
• Pre mature (within 37 weeks) labour pain
• Watery vaginal discharge / rupture of membrane
• Vaginal bleeding
• Vaginal discharge with foul smell
• Weak or no foetal movements
• Breathing difficulty even while resting or while
conducting smaller day to day activities
• Severe weakness/ tiredness
• Palpitations
These symptoms may be visible at any stage in
pregnancy. Even if at least one of these symptoms is
observed one must consider it seriously and refer to the
nearest health care centre. Educate the pregnant woman
and the family members on how to identify these signs
and ask them to be prepared to visit the nearest hospital
if any of these signs are observed-
Pre delivery/ birth preparedness (plan):
Ihe pregnant woman and the family members must
make a plan and be prepared for a safe and comfortable
delivery as well as for post-delivery care. ASHAs should
counsel the pregnant woman and the family members
during the ANC follow up visits ip;
• Choose a centre and a doctor who is able to provide
quality service aad care to the pregnant woman.
• Ensure that the pregnant woman is registered in the
first trimester
• Have Informatkin on the EDD date
• Complete a minimum of 3 check- ups at the health
centre
• Ensure that sullkient finances are arranged for the
delivery time
• Choose the appropriate mode of travel to the hospital
(Not to use bicycle, bullock cart) well ahead of the
EDD date and ensure that prior discussions are done
with the concerned so that vehicle reaches the house
well on time
• Prepare and keep the necessary clothes dean and
ready to be used for the nursing mother and baby
• Knowledge of danger signs during pregnancy and
referral opportunities to higher care centres
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I
SESSIONS: PROVIDING
INTRA-NATAL (DELIVERY)
CARE SERVICES
SESSION?:
USING THE HBMNC TOOL - SECTION 2 ANC
Objective
a
Methodology
Group discussion and
presentation
Duration
1 hour
Training Materials
Markers and brown sheets/ chart paper, and copies of
the HBMNC Tool (Annexure 1) and HBMNC Tool filling
guidelines (Annexure 2)
Tips for facilitators
Encourage the participants to clarify any
misinformation or doubts at this stage of the training.
• Ask participants what hinders them from
<(
making their home visits more effective.
• Note their responses on a flip chart
• Tell them that the HBMNC Tool supports their
efforts to overcome home visit challenges.
• Now tell them to look at Section 2 of the
HBMNC Tool.
• Read through each of the components in
Section 2 aloud and explain how and why this
section is important. Clarify any doubts that the
participants may have.
• Tell each participant to use an example of the
most recent home visit they conducted. They
can refer to their registers to obtain the woman’s
details if they cannot recollect it on their own.
• Allow 10 minutes to fill in Section 2 of the
HBMNC Tool using that information.
• Verify if all the entries are correctly filled in by
individually looking at formats randomly among
the group.
• Select one filled format randomly from the group
and discuss if it has been filled in correctly by
going over each of the indicators in plenary.
• Ask if there are any questions about how to fill in
Section 2.
• Consolidate the session:
- Understanding how to correctly fill the
information in Section 2 of the HBMNC Tool
is crucial.
• To help participants understand the care
needed during delivery and the complications
that may arise.
Methodology
Duration
PPP and discussion
1 hour
Training Materials
L.
Why is delivery care important?
The risk of mortality is the highest during and after delivery for
both mother and child.
Markers and brown sheets/ chart paper, and
copies of Information Guide for Session 8
Tips for facilitators
How many stages are there in delivery and what are they?
There are 4 stages of deiivexy/Ibcy are:
1st stage From the starting of labour pain till the complete
opening ofthe mouth ofthe womb (10cm dilation)
2nd stage: From the opening of the mouth of the womb till the
baby comes out
3rd stage From the time ofbaby has come out of the womb till
the placenta is discharged.
4th stage First two hours after the delivery
'■ . -
-
What are the danger signs during the delivery?
• Prolonged and obstructed delivery (More than the regular
time required for a normal delivery, taking more than 12
hours)
• Inconsistent/ very fast/very slow heartbeat of the foetus
(stressed foetus/foetal distress)
• Inability of the child to push the bead and shoulders way out
(obstructed labour)
. • Bleeding during pregnancy/rupture of membrane in
premature delivery/ non-ruptured membrane
• Infeetion/sepsis
• Umbilical cord comes out first (Cprd Prolapse).
• Yellowish or foul smelled, excreta mixed womb water oozing
out (Meconium stained liquor) •
. •_ Partial or non-discharge <jf placenta (incomplete/.retained
placenti))
• Fever, Fits, Excessive bleeding
’
This is a crucial session as correct information
given by FLWs regarding delivery care, and
problems that may arise during and after delivery,
could motivate the pregnant woman and family
members to seek institutional delivery.
Process
1
Key things to observe during delivery care:
• It is very important to haye the baby delivered by a skilled
doctors and assistants.
The ‘5 Cleans’:
1. Clean space /place: The delivery room should have sufficient .
ventilation and light This helps in infection prevention and •
keeps the child warm and clean
.
2. Clean hands: Helps in infection prevention
3. Gean/sterile blade: Prevents sepsis
4. Clean/sterlie thread: Prevents infection and pus formation
5. Clean cord - Do not apply anything on the umbilical cord to
prevent infection/scptic/pas and bleeding
■
t-.18 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Objective
INFORMATION GUID^ FOR SESSION 8
Process
• To introduce participants to Section 2 of the HBMNC Tool.
e
• Divide participants into three groups and
ask them to answer each of these questions:
- What are the stages in delivery?
- What are the danger signs during the
delivery?
- What is the 5 things that must be clean
before, during and after delivery? Why is
this important?
• Allow 15 minutes to discuss, and then ask
a representative from each group to take 5
minutes to share their responses.
• Ask other groups to share any other key
information.
• Continue with the next 2 groups in the
same manner.
• Use PPP and the pre-prepared chart
‘Information Guide for Session 8’ to
wrap-up all the presentations and provide
a complete picture of delivery care to the
participants. Use pictures of danger signs
to confirm the awareness levels of the
participants. (Refer to Module 2)
• Consolidate the session:
- Delivery care takes prominence as the risk
of mortality for both mother and child are
the highest during and after delivery.
- It is very important to have the baby
delivered by a skilled doctors and
assistants.
- As soon as a woman knows she is
pregnant she should start preparing for
delivery.
SESSION 10:
PROVIDING
PNC SERVICES
SESSION 9:
USING THE
HBMNC TOOL
SECTION 3 DELIVERY
e
e
Objective
©
■jj?
Duration
1 hour
Discussion and presentation
INFORMATION GUIDE FOR SESSION 10
Methodology
Duration
PPP/posters and group discussion
1 hour
Training Materials
Training Materials
Markers and brown sheets/ chart paper, and copies of
the HBMNC Tool (Annexure 1) and HBMNC Tool filling
guidelines (Annexure 2)
i
Markers and brown sheets/ chart paper and copies of
Information Guide for Session 10
Tips for facilitators
Tips for facilitators
Encourage the participants to clarify any misinformation
or doubts at this stage of the training.
!
;
I
I
This is a crucial session as it deals with the vital
components of maternal and new born care. ASHAs need
to be very clear the information and the message they
give at this stage to ensure the home visits are effective.
Process
Process
:
• Ask the participants to look at Section 3 of the
HBMNC Tool.
• Read through each of the components in Section
3 aloud and explain how and why this section is
important. Clarify any doubts that the participants
may have.
• Tell each participant to use an example of the most
recent home visit they conducted. They can refer to
their registers to obtain the woman’s details if they
cannot recollect it on their own.
• Allow 10 minutes to fill in Section 3 of the HBMNC
Tool using that information.
• Verify if all the entries are correctly filled in by
individually looking at formats randomly among the
group.
• Select one filled format randomly from the group
and discuss if it has been filled in correctly by going
over each of the indicators in plenary.
• Ask if there are any questions about how to fill in
Section 3.
• Consolidate the session:
- Understanding how to correctly fill the information
in Section 3 of the HBMNC Tool is crucial.
Cor
tyL
item
is fo
■ovin
temi
onat
: • Divide participants into three groups and ask them
i
to answer each of these questions:
; - What are danger signs and symptoms in a nursing
i
mother?
I
- What are detailed steps to take to address these
signs and symptoms?
;
- What are danger signs and symptoms in the
:
newborn?
!
- What are detailed steps to take to address these
;
signs and symptoms?
;
- How many times should an ASHA conduct a home
:
visit to a nursing mother and newborn?
■
- What are the key things she should observe during
these visits?
• Allow 20 minutes to discuss, and then ask a
;
representative from each group to take 5 minutes to
;
share their responses.
: • Ask other groups to share any other key information.
■ • Continue with the next 2 groups in the same
;
manner.
• • Use PPP/posters and the pre-prepared chart
IChii
• Consolidate the session:
- The first 42 days after delivery is a very crucial stage
for both mother and child.
- There is an increased risk for both mother and
newborn in the first week that may lead to death.
- Many mothers and newborn among the rural poor
in the eight priority districts in northern Karnataka
do not have access to PNC services.
Objective
• To help participants identify postnatal and newborn care
services and the danger signs possible during this stage
• To introduce participants to Section 3 of the HBMNC
Tool.
Methodology
‘Information Guide for Session 10’ to wrap-up all the
presentations and provide a complete picture of PNC
care to the participants. Use pictures of danger signs
to confirm the awareness levels of the participants.
(Refer to Module 2)
ihh:
hing
Kit
What do we mean by nursing mother and
newborn baby care? What is its importance?
Once the placenta is discharged from the body
during delivery the next 6 weeks is termed the
post natal care or PNC stage. Since there is an
increased risk of mortality of mother and infant
during this stage it is important that they receive
PNC sei vices.
What are the necessary services that should be
provided during the PNC? When and at what
frequency should the ASHAs make home visits?
From the time of delivery till the 6th week, i.e. on
the 3rd , 7th J4th,21st,28th and 42nd day after
the delivery ASHAs should make home visits. The
purpose is to observe any danger signs, counsel
the woman and family, and if necessary make
referrals to higher care.
Danger signs in the nursing mother:
• Excessive bleeding.and tenderness in the womb
• Painful and with foul smell lochia discharge
• Sepsis and infection of the nursing mother
• Fever/shivering with or without the swelling of
face and limbs, severe head ache and blurred
vision
• Difficulty in breathing or heavy breathing
• Breast abscess and infection
• Swelling and infection in die space between
vagina and anus
• Sense of burning during urination
•
•
•
•
»
•
•
•
•
Swelling in the stomach
Iambs hanging or weak
Bubbles filled with pus all over the body
Child s armpits and skin folding in the thighs
turning red
Eyes swollen and filled with pus
Belly button turns reddish and pus formed
Seizures and fits
Blood contaminated excreta
Limbs turnedyellowish
These signs and symptoms may quickly manifest
in the nursing mother or the newborn. Even
if there is only one sign visible this should be
considered serious and the mother or newborn
taken to a health facility.
PNC services include:
• Registering the child
• Providing home visits for regular care for the
nursing mother and tlie newborn
• Counselling the nursing mother on nutrition
(suggest intake of food with higher calorie and
iron content)
• Identifying danger signs in both mother and
newborn and immediate referral fur higher care
• Promoting exclusive breast feeding in the first 6
months
• Immunisingnewborn
• Providing family planning information and
services
Danger signs in the newborn:
• Foot appetite for breast milk or unable to
properly breastfeed
• Limited activity of the child
• Child suffering from fever or cold skin
• Difficulty in breathing or chest in-drawing/
grunting
• Child doesn’t cry or makes a feeble cry
Des
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SESSION 11:
USING THE HBMNC
TOOL-SECTION 4 PNC
4^ Objective
• To introduce participants to Section 4 of the HBMNC Tool.
Methodology
Duration
Group Discussion and
presentation
1 hour
Training Materials
Markers and brown sheets/ chart paper, and copies of
the HBMNC Tool (Annexure 1) and HBMNC Tool filling
guidelines (Annexure 2)
e
Tips for facilitators
Encourage the participants to clarify any misinformation
or doubts at this stage of the training, especially
related to the terminology used in Section 4 of the
HBMNC Tool.
Process
Process
• Ask the participants to look at Section 4 of the
HBMNC Tool.
• Read through each of the components in Section
4 aloud and explain how and why this section is
important. Clarify any doubts that the participants
may have.
• Tell each participant to use an example of the most
recent home visit they conducted. They can refer to
their registers to obtain the womans details if they
cannot recollect it on their own.
• Allow 10 minutes to fill in Section 4 of the HBMNC
Tool using that information.
• Verify if all the entries are correctly filled in by
individually looking at formats randomly among the
group.
• Select one filled format randomly from the group
and discuss if it has been filled in correctly by going
over each of the indicators in plenary.
• Ask if there are any questions about how to fill in
Section 4.
• Consolidate the session:
- Section 4 was designed to facilitate early detection
of danger signs and symptoms among the nursing
mother and newborn by the ASHAs in the
designated area.
- Early detection enables speedy and effective referral
linkages to higher care.
- Understanding how to correctly fill the information
in Section 4 of the HBMNC Tool is crucial.
• To help the ASHA understand where,
when and how counselling should be
done during PNC home visits.
Training Materials
Methodology
Role plays, question and
answer session and discussion
© Duration
1 hour
Role Play Scenario 1:
Radha is 25 yrs old and is pregnantfor the 2nd time.
She is in the Sth month ofpregnancy. Her first child is
2 years old and was delivered at home. She with her
husband had gone to Bangalore for work and returned
to the ASHAs area just one week ago. During herfirst
ANC check-up she was diagnosed with severe anaemia.
Today is your second home visit to Radha’s house. Per
form a role play ofyour home visit.
Role Play Scenario 2:
Pavithra is 28 years old. She delivered a baby girl 3
days ago in a PHC. Delivery was normal and the baby
weighed 2.5 kg. She stayed in the PHCfor 48 hours
after which she got discharged and went back home.
Today the ASHA is planning to do the first PNC visit to
Pavithras place. Perform a role play ofyour home visit.
• Allow 15 minutes for the group members to read it,
discuss and prepare the play.
• Ask each group to perform their role play.
• Ask the participants to think about the role play that
they watched and share what they felt about the way
the ASHA conducted the home visit
Markers and brown sheets/ chart
paper, copies of case studies and
copies of Information Guide for
Session 12
Tips for facilitators
Encourage ASHAs not to be discouraged if they have had unsuccessful attempts trying to change behaviour among
families of pregnant or newly delivered mothers. Tell them to share their experiences, but to listen to suggestions from
other participants on how to successfully counsel that family. Create opportunities through the session for cross sharing and
learning among the participants.
22 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• Ask the participants if they saw any gaps in the
interaction between the ASHA and the new mother
or her family.
• Note their responses on a flip chart
• Ask the participants if the ASHA could have done
anything else to make the counselling more effective
and focused?
• Note their responses on a flip chart
• Ask the participants what skills does the ASHA need
to identify problems and offer solutions or corrective
measures through counselling?
• Note their responses on a flip chart.
• Use the pre-prepared chart ‘Information Guide
for Session 12’ to review tips for successful PNC
counselling during home visits.
• Consolidate the session:
- Delivery and child birth related beliefs and customs
and lack of access to correct information stop
nursing mothers and their families from adopting
good health practices.
- Challenging these beliefs becomes a key focus of
most of the counselling sessions that the ASHA has
during her PNC home visits.
- Education and awareness among families and
mothers through the ASHA is the only way to put an
end to such practices.
INFORMATION GUIDE FOR SESSION 12
1. Rapport / relationship building
This is lhe foundation for ugoud relationship
between the ASHA and the pregnant woman.
A Iways try to make the pregnant women
comfortable by greeting her with appreciating
words, motivational gestures such as a smile on
yourface, patting on the hand, etc. Any home visit
has to begin with exchanging greetings between
the ASHA, woman and any other family rnember s
present.
SESSION 12:
PNC HOME VISITS: HEALTH
EDUCATION AND COUNSELLING
Objective
• Give one of the role plays to each of the two groups.
2. Assessing the knowledge of the pregnant women
family members
In every home visit (1st visit or follow up visits,
it is important to assess what the woman knows.
For example, what does she knows about having
nutritiousfood during pregnancy? What did she
understandfrom the ASHAs last visit. For example,
did she follow any of the advice given? Based on
this understanding, the ASHA can plan to provide
additional messages.
3. Screenfor danger signs
It is important to quickly screen the woman or
newborn during every home visitfor any of the
danger sign?. Always observe, examine and inquire
if everythin is OK. “See’', ‘'Touch" & ‘Ask” are
the three key words in home visits to identify any
danger signs or complications.
4. Dialogue/ asking open ended questions
By itiiiiaiing dialogue you can elicit or gather the
information using open ended questions Open
ended means notjust a simple ‘yes' or 'no question,
but asks 'who, 'where, when’, 'why', 'what' or
‘how’. By asking open ended questions you will able
to gather information in more, than one or more
sentences.
5. Using right fEC materials
To make your communication more effective it
is important to use appropriate IEC materials in
every' home visit and us needed. Try to use pictures.
Design, Planning and Implementation of the Sukshema Project 23
posters, pamphlets to make people curious and to
start a dialogue. See Session 13 m Module 6.
6. Counselling
Proride correct infonmuion, breaking down
difficuh tasks or ideas into smaller steps that can
be easily understood orfollowed.
7. Focusing on thefamily
Each family has a different structure. By developing
a rapport v.-iih the woman and with otherfamily
members you wiU be able io identify who is the
decision maker in thefamily, or possibly find there
are several people that have the power to make
judgments about social offuianeiai issues. These
decisions or judgments could influence the woman’s
health seeking behavior. Through your dialogue
with the woman and herfamily members identify
the decision makers. Then focus your messages on
thae family members. For'examplel if a wvman’s
grandmother is the reason for taking decision to
have a home delivery, have dialogues with the
grandmother to convince her about the benefits of
tin institutional delivery Homr visits can be more
efftxiive ifyou join up with anA1VTV’ JH.4 ora
VHSNC meiubcr.
8. Communication skills
Probing, interring, paraphrasing/sumtnarizing are
all important skills to use while communicating
with the woman and her family members.
Paraphrasing means that a fter you gather
information you then restate the words said by
the person. For example, you might say, T think
you said that you are afraid ofhaving a home
delivery because ifsomething went wrong there
is no transportation available co take you to a
health facility Is this correct?’ This will help her
to understand that you were listening and want
to continue the conversation. You can also ask the
woman to reinstate the messages given by you in her
own words. This will help you to assess Ihul she has
understood.
SESSION 13:
INTRODUCING
IEC MATERIALS
9. Foliou up
Always give a follow-up date and timefor your next
home visit. If the woman has so make a follow-up
visit to a health facility, always make sure that the
date and time is convenientfor her and that there
is no misunderstanding about the purpose. Ask her
to repeal what she understood by the details of the
follow-up appointment and to recollect any action
she needs to take. This is critical and will help you
to sec any trend in behaviours over time so you can
plan your home visits accordingly.
Objective
• To help the participants understand the
importance of IEC materials for effective
communication during home visits
Methodology
Duration
Demonstration of
reminder cards
30 minutes
Training Materials
10. Filling the results of the home visit in the
HS.MNC checklist
Once you completed the home visit, record the
results in the checklist while you are still at
the house. Ihis should help you to remember
any messages ifyou have forgotten during the
interaction. Ifyou wait too long to fill in the
HBMfiCform, you might forget some critical
information.
ASHA reminder cards (Annexure 3)
Tips for facilitators
Demonstrate the use of these cards by giving
examples. The cards should assist the ASHA to be
a more effective communicator, and not hinder her
communication during home visits.
Process
• Ask the participants how they could make their
communication more effective during home visits.
• Note their responses on a flip chart.
• Highlight any responses related to using
appropriate IEC materials to be more effective.
• Ask them for some examples of IEC materials.
• Give one set of reminder cards each to the
participants (Annexure 3).
• Tell the participants:
- These illustrated reminder cards were developed
based on the messages given in the HBMNC
checklist
- The HBMNC checklist will help an ASHA to
identify the issues, and the reminder cards will
help an ASHA to communicate the correct
message.
- ASHA should always carry the reminder cards
with her, which is easy as they are the size of
visiting cards.
'' - ■ -'--M J
- Illustrations were developed based on 8 themes and
linked with the messages provided in the HBMNC
checklist, including birth planning & preparedness,
danger signs in pregnancy, anaemia, danger signs
during delivery, danger signs in newly delivered
mother, danger signs in newborn, newborn care and
family planning.
- Cards are colour-coded based on the 8 themes. An
ASHA can easily find the correct cards depending
on what she wants to communicate. For example,
if she identifies the need for counselling women on
family planning, she will use the green coloured
cards.
- The cards can be used like a flip chart if there is a
small group of people she is counselling.
• Demonstrate how to handle the cards. Ask the
participants to hold the card so the information is
available and to flip the card over without dropping it.
• Ask if there are any questions about using the cards.
• Consolidate the session:
- Reminder cards can make home visits more effective
and interesting.
De
'■‘lanr
ndlr
rent.
if th
their
iect
SESSION 14:
PRACTICAL USE OF
THE HBMNC TOOL
Objective
• To provide hands-on experience in filling in the
HBMNC Tool
Methodology
Field work and home visits and group work
and discussion
a
Duration
2 hours
Training Materials
Markers and brown sheets/ chart paper, and copies of
the HBMNC Tool (Annexure 1) and HBMNC Tool filling
guidelines (Annexure 2)
Tips for facilitators
Make plans for the field work and home visits in
advance and ensure that there is no confusion during
the home visit or any kind of inconvenience to the
mother, baby or other family members. Encourage
every participant to fill in the Tool during the visit
It Process
• Plan a short field visit in the nearby village/ SC or
PHC area.
• Identify three houses that either have a pregnant
woman, a recently delivered mother and newborn, or
a PNC case available.
• Make prior arrangements so the visit is planned
at a suitable time with the family’s approval and
cooperation. Confirm the arrangements close to the
date and time.
• Divide the participants into 3 groups and distribute
one copy of the HBMNC Tool and one copy of the
guidelines to each person.
• Arrange for one project staff to accompany each of
the three groups to each of the three houses.
• On reaching the house, the ASHA will introduce the
purpose of this exercise to the woman and her family.
• Then the ASHA will conduct the home visits as per
the guidelines.
• The participants in the group will fill the HBMNC
format while Ustening to the conversation between
the woman and the ASHA.
• At the end of the home visit each group will return t
the training site.
• On returning, ask them about their experience in the
field.
- Was the home visit a positive experience? If yes,
why? If no, why not?
- Did the HBMNC Tool assist them during the home
visit?
- Were there any sections that they could not fill in?
• Let everyone have a chance to share.
• Select one filled format randomly from the group and
discuss if it has been filled correctly by going over
each of the indicators in plenary.
• Collect all the filled formats and verify some of them.
Make the needed corrections.
• Consohdate the session:
- Participants will gain hands-on experience in using/
filling the HBMNC Tool during their home visit
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
...
SESSION 15:
TRAINING
EVALUATION
AND FEEDBACK
r Ms®
TRAINING EVALUATION AND FEEDBACK FORM:
■
KARNATAKA HEALTH PROMOTION TRUST
Training Evaluation and Feedback Form
>
Place of training:
Designation:
Name:
Training dates:
Name of the PHC:
■■■■■
S.No.
© Objective
• To assess what affect the module had on the participants'
attitudes, knowledge and practice levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for enhancing
future effectiveness.
:
Training content and sessions
2
Training methodology and activities used
3
Training skills of the facilitators
4
Logistics at the training (Food, stay and comfort)
5
Relevance
and usefulness of training
F
Duration
1.
30 minutes
2.
Tips for facilitators
The training evaluation and feedback form will assess
what affect the module had on the participants' attitudes,
knowledge and practice levels and obtain feedback on the
usefulness of the training and suggestions for enhancing
future effectiveness.
Good
Poor
List the three aspects of the training that you found most useful.
Methodology
Training evaluation and feedback form
;
;
:
:
■
1
Reflection
Training Materials
Excellent
Subject
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
1.
2.
3.
What are the three most important lessons that you can take back to your wor•rk place from this training?
1.
Process
2.
• Distribute the training evaluation and feedback form.
Go over all the areas that the participants will need to
think about while filling it in.
• Allow 20 minutes to complete it.
• Collect the training evaluation and feedback forms
from the participants.
• Before the dosing ceremony begins, ask the
participants to share their feelings about the training:
encourage anyone who is keen to orally share two
positive aspects and two areas that need improvement
• At the closing ceremony thank all the participants for
their enthusiastic participation, congratulate them and
wish them the best as they go back to their own field
areas and begin to initiate the intervention on ground.
• Thank everyone else who contributed to the training
program. This might have induded administrative
staff, venue owners, facilitators, guest speakers and the
organizers.
Co
lityl
met
>ns f.
>rovii
iten
>ona
dCh
•aith
lining
Kit
3.
Please list suggestions for improved facilitation in future trainings.
r
De
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th
sherr
■'ject
.J!.
'i-
ANNEXURE 1!-.HBMfJC Tool
B. COMPLAINTS £;
Project Sukshema
Department of Health, Government of Karnataka
^jflp^uksht?ma|
IqonKMawAlKvuQXrM is»a
HOME-BASED MATERNAL AND NEWBORN CARE TOOL FOR ASHAs
(Use pee F.pWi fpr each moths' cor tacied during preg-ancy and p' EACH ripme visit wid’in '’-/days aPe* cel very. II you mee’ the
woman ouls de her home, do nor-consider tnai as a <ome ' is i>
L;.
1 .District
2.Taluka
4.Subcentre Location.
6.ASHA Name_
h rifr
v c^. ¥ box . tHP-anr ana.; .
.i.y oi U-.': *-:‘!Lr.wn
National Rural Health Mission
3. Fever
¥□ ND
YD ND
YD ND
YQ ND
YD
4.Swelling efface
YD ND
YD ND
YD ND
YD ND
YD ND
S.Headache
YD ND
YD ND
YD ND
YD ND
YD ND
6.Blurred vision
YD ND
YD ND
YD ND
YD ND
YD ND
7.Vomiting
YD ND
YD ND
YD ND
YD ND
YD ND
S.Fits/seizures
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
ND
3.PHC Location
9.Difficulty in passing urine/ less urine
YD ND
YD ND
YD ND
S.Village Name.
lO.Palpitation
YD ND
YD ND
YD ND
YD ND
YD ND
11 .Severe weakness/tiredness
YD N D
YD ND
YD ND
YD ND
YD ND
12.Breathlessness at rest or on mild exertion
YD ND
YD ND
YD ND
YD ND
YD ND
IS.Pain in abdomen
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD ND
YD ND
YD N D
YD ND
7. ASH A Area Name
■
B. WOMAN'S BACKGROUND INFORMATION fr :<Mripfet<rt«>si^criE*rMirourW
Ask. the ■.'•cman.and. or
tlm ."nayi ca/d tf yoahay^ npl Who iril.tt.er-J<:rr}Kiti©nuh
(cinariflig tnf0'fn.?udh
IS.Total pregnancies
14.Contractions
9.Husband's name
19.Total live births
YD ND
YD ND
YD ND
YD ND
20. Total abortions
IS.Watery discharge per vagina/ rupture
of membranes
YD ND
lO.Age [
16.Bleeding per vagina
YD ND
YD ND
YD ND
YD NO
YD ND
17.Foul discharge per vagina
YD ND
YD ND
YD ND
YD ND
YD ND
18.Decreased/no foetal movement
YD ND
YD ND
YD ND
YD N D
YD ND
4
5
8.Name.
] ys
11 .BPL YD N D Caste/Tribe SC D ST D Other D
21. Total living children
12.Permanent address Same village D
Other village within PHC area D
Other village outside PHC area D
22. Age of the last child |
23. Any complications in previous pregnancies?
YD N D
1 S.Phone number |
14. Thayi card number I
|
I
I
I
I
I
I
|
|
I
|
~| Year |
|
19.Any other (specify)
24.Any previous C-sections/assisted delivery?
YD N D
|
15. Date of registration Day
Month |
~| months
|
Home visit number
25.Any of the previous home deliveries?
YD N D
~]
2] Month [ 1
26.LMP Day [
16. Place of registration Within PHC area D
Outside PHC area D
27. EDD Day |
|
| Month |
|
2
I Year | |
|
| Year |
|
|
28. Gestational type Single pregnancy D
Multiples D
A. VISIT DETAILS ti'eoxudeuek jl tiaja ANC twre vis.: in me axr^spw«i'.Tj4
■•vh ^h you
vrQman. You aravrawx-didmake
•kxii
vsfticrs
for hgft-'iski.pgjn.jr.t
'Q1-theday.on.
5*Alh.,8th. and%t»mcnt)K'«rfptegnapcy
deti:|s.ii adcfit<f.al .Visits are..
ANC home visit number
1
2
3
4
5
1 .Visit date (dd/mm/yy)
2.Gestational age (in
months)
n~I
CD
m
30 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
[=□
m
3H
20.Haemoglobin
YD ND
YD ND
YD ND
YD ND
YD ND
21 .Blood group/Rh
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
22.
YD ND
YD ND
YD ND
23.
YD ND
YD ND
YD ND
YD ND
YD ND
24.HbsAg
YD ND
YD ND
YD ND
YD ND
YD ND
25.Urine for protein
YD ND
YD ND
YD ND
YD ND
YD ND
26.Urine for detection of infection
YD ND
YD ND
YD ND
YD ND
YD ND
27.
YD ND
YD ND
YD ND
YD N D
YD ND
28.0ther( Specify)
YD ND
YD ND
YD ND
YD ND
YD ND
Design, Planning and Implementation of the Sukshema Project 31
.
YD ND
297XNC check up done?
If yes record the date
Date
/
/
YD ND
YD ND
Date^<_/_ Date
YD ND
Date
/_
/
1
YD ND
Date
/
/
D CHC
TH
D DH
Pvt
D Other
D PHC
D CHC
D TH
DH
D Pvt
D Other
D PHC
CHC
D TH
D DH
D Pvt
D Other
D PHC
31 .TT injection dose
YD ND
YD ND
YD ND
32.TT injection booster
YD ND
YD ND
YD ND
YD ND
YD ND
33.IFA tablets
YD ND
YD ND
YD ND
YD ND
YD ND
34.Was weight recorded?
YD ND
YD ND
YD ND
YD ND
YD ND
35.Was BP recorded?
YD ND
YD ND
YD ND
YD ND
YD ND
36.Was abdominal examination
recorded?
YD ND
YD N D
YD ND
YD ND
YD ND
37.Was foetal heart rate recorded?
YD ND
YD ND
YD ND
YD ND
YD ND
30. Place of ANC check done
(Tick the place)
YD ND
48.Birth planning and preparednessPromotion of delivery in a facility
YD ND
YD ND
YD ND
YD ND
YD ND
49.Antenatal checkups in a facility
YD N D
YD ND
YD ND
YD ND
YD ND
SO.BIood and urine tests
YD ND
YD ND
YD ND
YD ND
YD ND
51.Nutrition and rest during pregnancy
YD ND
YD ND
YD ND
YD ND
YD ND
52.Signs and symptoms of anaemia
YD ND
YD ND
YD ND
YD ND
YD ND
53.Prevention and treatment of anaemia
including consumption of IFA tablets.
Side-effects of IFA tabletsV
YD ND
YD ND
YD ND
YD ND
YD N D
YD ND
Pregnancy outcome: Abortion D
RISKS DURJ.NGTBE-GNANCY
^pregnancy rompteaUaph- ^*4 e-7 co-*
I
day I
1 .Delivery date
2. Place of delivery
month |
I
|
Delivery
year
|
SC D PHC D CHC D TH D DH D PVT D Home D Other D
S.Name of institution
-
38.Short primigravida (First
pregnancy and height <4’10")
/ ' ?>‘7 -i’
4. Delivery outcome Live birth D Still birth D
YD ND
39.Severe anaemia (<7gms%) YD ND DKD YD ND DKD YD ND DKD YD ND DKD YD ND DKD
5. Delivery type Normal D
C-section D
7.Birth weight |
|
|
|
|
YD ND DKD YD ND DKD YD ND DKD YD ND DKD YD ND DKD
41.Previous caesarean
section/still birth/ abortion/
preterm birth
YD ND
42.Grand multi parity (3+)
YD ND DKD
6.Sex of the child
gms 8. Date returned home day |
|
Male D
| month |
|
Female D
| year
I
9.Complications during delivery and postpartum period None D Mother died D Obstructed labour D
Postpartum haemorrhage D
4O.Pregnancy induced
hypertension/ eclampsia
Newborn diedrD
Assisted D
Child died D
Pre-eclampsia D
Child developed infection D
Eclampsia D
Mother developed infection D
Asphyxia D
LBW (<2500 gms) D
Preterm birth D
Other D (Specify)
43.
44.Ante partum haemorrhage YD ND DKD YD ND DKD YD ND DKD YD ND DKD YD ND DKD
PNC home visit number
1
45.
2
3
5
4
6
1 .Visit date (dd/mm/yy)
46.
47.Pregnancy with HIV/
diabetes/heart disease/
other health complaints
YD ND DKD YD ND DKD YD ND DKD YD ND DKD YD ND DKD
2.# of days since delivery
m r~n
3.Record her temperature in Celsius.
If the temperature >37.5 degrees Celsius,
administer the first dose of paracetamol and
refer to a health facility
Co
>ity L
rrter
ns f<
•rovii
tterr
lona
J Ch’
akh:
■ininj
Kit
m m m
[ i
m m m m m n~i
Des
olann
id In'
lentr
if thf ' ' shem
oject
PNC home visit number
4.Are her breasts hard/ nipples
hard or broken/ experiencing
pain in the breasts or the
nipples? If YES, counsel her
on right positioning and
attachment of baby to the
breasts, before referring to a
health facility
S.Does she experience
difficulty in breathing?
t
16.1s the baby in-active?
YD ND
YD ND
YD ND
¥□ ND
¥□ ND
YD ND
17.Are the baby's eyes
swollen and discharging pus?
YD N D
YD ND
YD ND
YD ND
YD ND
YD ND
18.
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
19.Are the baby's skin folds in
arms and thighs red?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
20.Does the child have boils
filled with pus?
YD N D
YD N D
YD ND
YD ND
YD ND
YD N D
21.
YD ND
YD ND
YD ND
YD N D
YD ND
YD ND
22.1s the baby not crying at
all or has a feeble cry?
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
23.1s the baby's tummy
bloated/ distended?
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD ND
24.1s the baby vomiting?
YD ND
YD ND
YD ND
YD ND
YD ND
YD NO
25.Does the baby have
difficulty in breathing and
chest in-drawing?
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
26.1s the baby breastfeeding
poorly. If YES, determine if
the issue is positioning and
attachment and provide
counselling. If breastfeeding
does not improve with
counselling, refer to a
health facility for further
assessment." Although poor
breastfeeding can be due to
latch/attachment, it can also
be a sign of sepsis.
YD ND
YD N D
YD ND
YD N D
YD ND
YD ND
27.1s there redness or pus at
the cord stump?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
1
2
3
4
5
6
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
1
2
3
4
5
6
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD ND
YD ND
6.1s her uterus soft and does
she have excessive bleeding?
If YES, provide uterine
massage and advise
breastfeeding before
referring to a health facility
YD ND
7.Does she have pain and
foul-smelling lochia discharge
from the vagina?
YD ND
8.1s she experiencing fits?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
9.1s she experiencing severe
abdominal pain?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
lO.Does she have burning
micturition?
If YES, advise more fluids
before referring to health
facility
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD N D
YD ND
YD ND
YD ND
f> vrtxrci the.:nfa(MtWa
11 .Record the baby's
temperature in Celsius. If the
temperature >37.5 degree
Celsius or <36.5 degrees
1 Celsius, refer to a health
m m
m
Home visit number
I facility
12.Does the baby have fits?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
13.1s the baby passing urine
less than 6 times a day?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
14.1s the baby having
diarrhoea?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
15.1s there blood in baby's
stools?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
34 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
28.# of full meals (and drinks)
she had in the past 24 hours.
If <3, discuss with her the
reasons, and advise her or
link her to other schemes/
facilities as required.
29.Does the mother avoid
any food and fluids? If YES,
counsel her on balanced diet
Design, Planning and Implementation of the Sukshema Project 35
‘“4-
¥□ ND
¥□ ND
¥□ ND
YD ND
¥□ ND
¥□ ND
¥□ ND
¥□ NO
¥□ ND
¥□ NO
¥□ ND
¥□ NO
¥□ ND
¥□ ND
YD ND
YD ND
YD ND
¥□ ND
¥□ N
¥□ ND
i.Pustules on skin or boil
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
j. Not passing urine at
least 6 times a day
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
k. Pus/ inflamed red
umbilicus
YD ND
YD N D
YD ND
YD ND
YD N D
YD ND
I.Blood in stool
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
44.Childhood immunizations
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD N D
YD ND
YD ND
YD ND
YD ND
YD ND
1
2
]
30.# of times the baby
breastfed in the past 24
hours. If <7-8 times, advise
her on the importance of
breastfeeding discuss the
reasons and advise her
accordingly.
c
O)
'tn
O
cp
YD N D
YD ND
YD N D
YD ND
YD ND
e.Hypo/hyperthermia
¥□ NO
¥□ ND
f.lcterus/ yellow skin
¥□ N
g.Stiff (body arched) or
sloppy
¥□ Mm
h.lrritability/ lethargy
31 .Is she feeding the baby
anything other than breast
milk, including water, honey,
sugar etc.?
YD ND
32.Has something been
applied to the cord stump?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
33.1s the baby kept warm?
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
34.Has the baby been given
BCG?
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
35.Has the baby been given
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
45.Breastfeeding - right
positioning and attachment of
the baby to the breast
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
46.Breastfeeding - exclusive
breastfeeding
c
o
t
Z
Polio 0?
36.Has the baby been given
Hep B 0?
PNC home visit number
tassassisi:
38.Keeping the baby warm
■ yd nqBYD ND
YD N D
YD ND
YD N D
■
4
5
6
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD ND
YD N D
YD ND
47.Breastfeed!ng - timely
complementary feeding
YD ND
YD N D
48.Nutrition - increased
calorie uptake, iron
supplementation and plenty
to drink
YD ND
49. Counselling on care of
the newborn during ARI/
breathing problems/fever
3
39.Cord care
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
4O.Cleaning/bathing the baby
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
YD N D
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
b.Convulsions
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
c. Blurred vision/severe
headache___________
YD ND
YD N D
YD ND
YD ND
YD N D
YD N D
50. Counselling on care of the
newborn during diarrhoea
and vomiting
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
51 .Family planning
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
e.Foul discharge or odour
YD ND
YD ND
YD ND
YD ND
YD ND
YD N D
f. Breathing difficulty
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
52.Woman/child referred to a
health facility?
YD N D
YD ND
YD ND
YD ND
YD ND
¥□ ND
YD ND
YD ND
g. Swollen/ red/ tender
breasts
h.Pain/ difficulty in
passing urine
YD N D
YD ND
YD ND
YD ND
YD NO
YD N D
53.Facility referred to
i.Worsening abdominal pai n Y D ND
YD ND
YD ND
YD ND
YD N D
YD ND I
j.Worsening perineal pain
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
D PHC
D CHC
D TH
D DH
D Pvt
D Other
D PHC
D CHC
D TH
D DH
D Pvt
D Other
D PHC
D CHC
D TH
D DH
D Pvt
O Other
PHC
D CHC
TH
DH
Pvt
Other
D PHC
D CHC
D TH
D DH
D Pvt
D Other
D PHC
D CHC
D TH
D DH
D Pvt
D Other
a.Breathing difficulty
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
b.Feeding problems
YD ND
YD N D
YD ND
YD ND
YD ND
YD ND
c.Convulsions
YD N D YD ND
YD ND YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
YD ND
of th
ksherr ~ oject
41 .Care for baby's eyes and
ears
a. Fever
c
ui
'v>
o
U)
_g
d. lncreased bleeding
I
54.Reasons for referral
d.Diarrhoea/vomiting
i Cc
nity.
Intel
ons I
prov.
aten
eon«
dCI
saltF.
ainin
IKit
55.Next follow-up visit date
(dd/mm/yy)
De
Plan'
indlr
■nent
A A
A A
" •- e7# W
W-W
W: ’A
ANNEXuRE 2. - HBMNC» filling
guidelines:
•
es, ’ T....Jja
Project Sukshema
Department of Health, Government of Karnataka
National Rural Health Mission
'WP^ukshemal
awrtiliwn »Owt ikaa
'•
If the p.'opet
has r<ovb«en
gi pw^esspes^^r5*5^
c.
INSTRUCTIONS FOR FILLING UP HBMNC TOOL
Use-gne Fonn lor esc- mo'her cciractec du« -g pjegnancy at>d for EACH f tcne Vib •
ou'sipe lie< ’’ome. do "ot consider that as a hc-ne v-sir.
-A. ViSl cm tTAiLS
C.-’ta.C
card. ANC
delivery. It you meet the woman
rj.TrJust visa
.-nat irwnc
ait, ch .cj uwet thepregnant v-.v-w..You aic.adv3ad tomcko
Arot<c--.ai rs?.< 3^ ntcetcery srr
wpmarf Jrurs
•**’•*’U
W.-aKi9tV.nw4^s4pi6jr*5qfcY
deUiL- U:«.ddi«iom»lyhds am ■
ANC home visit number
1
1
2
[
3
20.Haemoglobin
This test is done to check if the woman is anaemic
21.Blood group/Rh
If you know the blood group and RH beforehand, it becomes easy to
arrange for blood in case of urgent necessity. RH tells us if the blood
group is either negative or positive
day er.
22.
4
5
23.
1 .Visit date (dd/mm/yy)
Ex. Each time record the date of home visits in the respective column
Ex: 16/08/10__________________________________________________________
24.HbsAg
This helps to identify presence of jaundice
2.Gestational age (in
months)
Record the completed months of pregnancy on the date of your visit
Ex. 2,4,8 etc.
25.Urine for protein
If there is presence of higher levels of protein, there is possibility of
issues eclampsia / pre eclampsia / fits, understand the status and take
treatment if needed
26.Urine for detection of infection
This test is done to find out if there any Urinary tract infection
;• B. COf^P'-AiNTSXthjj cig each vijs. SJ|.
3.Fever
'
•
4.Swelling efface
S.Headache
•
6.Blurred vision
7.Vomiting
•
Use the BCC tool and educate on the danger signs
that may be observed in pregnant. Also inform about
the need for immediately go to the health centre and
ensure that they go
Ask /examine if any of the mentioned symptoms are
present. Inform her/family members about the need
to go to the health centre.
In case if the pregnant is tensed ensure that you instil
courage to her/family members
S.Fits/seizures
9. Difficulty in passing urine/ less urine
10. Palpitation
11.Severe weakness/tiredness
12.Breathlessness at rest or on mild exertion
13.Pain in abdomen
27.
D. ANC CHECKUPS v
29.ANC check up done?
If yes record the date
•
•
SO.Place of ANC check done
(Tick the place)
•
•
31.TT injection dose
Educate about the pregnancy check ups
In case if the pregnant has not done any check-ups , explore reasons anc
counsel appropriately with the pregnant and family members
Ensure that the pregnant does in time pregnancy check ups
Knowing the place of check-up helps in following up with the health
centre
•
This is administered to prevent Tetanus infection
•
•
•
There can be excessive bleeding because of being anaemic
Tell her about the importance of taking IFA tablets
Ensure that she takes these tablets. If NOT discuss the reasons and
counsel accordingly
Give attention in this regard in every visit
32.TT injection booster
33.IFA tablets
14. Contractions
15.Watery discharge per vagina/ rupture
of membranes
16.Bleeding per vagina
Apart from the problems mentioned here if there any other tests are
done (sputum , malaria, bilirubin) record in "Others" column
28.Other( Specify)
•
34.Was weight recorded?
•
The pregnant should check her weight in every visit. During
pregnancy the body weight should increase at least by 10-12 Kgs
35.Was BP recorded?
•
There is a possibility of danger to the pregnant because of low or high
blood pressure, so it's important have regular check-up and monitoring
36. Was abdominal
examination recorded?
•
This helps understand the status of position(if it is slanted) in which
the child is in the womb
•
This is very crucial to know the health status of the child
17.Foul discharge per vagina
18.Decreased/no foetal movement
19.Any other (specify)
37. Was foetal heart rate
recorded?
38 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Design, Planning and Implementation of the Sukshema Project 39
£E. RfSI^DURfNG PREGNANGY {CneckrteTh^
prognahcy
FW.a i cw Y w» if the cofppkanon ts present and refer
55. Breastfeed!ng - early initiation and
colostrum feeding
wpinaa !p ife? he arpst
56. Counselling to undergo HIV test
38.Short primigravida (First
pregnancy and height <4'10")
•
•
39.Severe anaemia (<7gms%)
•
40. Pregnancy induced
hypertension/ eclampsia
Educate on the symptoms of obstruction / complications
If there are any symptoms educate her on the need of in time
check-ups, additional examinations and care. Ensure that that
these are done and followed up
In case if the pregnant is tensed ensure that you instil courage to
her/family members
57.Contraceptive counselling
58.Government schemes
59.Danger signs during labour
60.VHND
41. Previous caesarean
section/still birth/ abortion/
preterm birth
61.Thayandira Sabhe
62.lf moving out of the area, how to
remain in the care continuum
42. Grand multi parity (3+)
43.
..... -
44.Ante partum haemorrhage
63. Pregnant woman referred to a health
facility?
45.
64. Facility referred to
46.
65. Reasons for referral
47.Pregnancy with HIV/
diabetes/heart disease/
other health complaints
66.Next follow-up visit date (dd/mm/yy)
Pregnancy outcome: Abortion
F CQUNS^^Ga ,
Delivery
_____________________________________________________ ____
48. Birth planning and preparednessPromotion of delivery in a facility
1 .Delivery date
49. Antenatal checkups in a facility
2. Place of delivery
50.Blood and urine tests
SC
day |
|
PHC
CHC
|
TH
4. Delivery outcome Live birth
PVT
[
|
Other
Home
7.Birth weight |
53.Prevention and treatment of anaemia
including consumption of IFA tablets.
Side-effects of IFA tabletsV
|
|
|
Newborn died
Still birth
C-section
5. Delivery type Normal
52.Signs and symptoms of anaemia
Assisted
6.Sex of the child
| gms 8. Date returned home day |
9.Complications during delivery and postpartum period None
Postpartum haemorrhage
Child died
ANC home visit number
2
1
3
4
5
Other
Pre-eclampsia
Child developed infection
|
Female
Male
| month |
Mother died
| year |~ ;
|
Obstructed labour
Mother developed infection
Eclampsia
Preterm birth
LBW (<2500 gms)
Asphyxia
(Specify)
- z
a. Severe anaemia_________
_______________
b. Fever__________________
T>
year |
|
DH
3. Name of institution'
51 .Nutrition and rest during pregnancy
O)
|
month |
c. Bleeding_______________
C
O)
d. Headache/ blurred vision/
vomiting/ fits
’w
ai
,.2^ and42nd<^1
e. Water discharge/ leaking
membrane_______________
Q o)
,•/
t, *! -Zno-viSit^The sewnG ^tQbecwijattctfjd^.ihe
V
-<uel.w»y bye;.i jfyov are
rwne.vts*
f. Labour pain >12 hours
ubaalUMa
0 C
inity
Inte
■ons
pro\
latei
Icon
viC
eaM
■ainii
>IKit
De' • Planr' •andl'-
of th"''■'ksherr* °roject
■t;;^^1th to vtKd^S^
H
PNC home visit number
11 .Record the baby's
temperature in Celsius.
12.Does the baby have fits?
•
•
1st visit (0-5) 12nd visit (6-10) 13rd visit (11-17)14th visit (18-24)1 Sth visit (25-35)16th visit (36-42)
1.Visit date (dd/mm/yy)
•
Mark the date of every home visit at the respective space Eg: 13.11.11
2.# of days since delivery
•
Please write the details of every post natal care home visit in the
respective space provided.
Count the number of days since delivery till the home visit and
mark the same Eg: 3
•
13.1s the baby passing urine
less than 6 times a day?
14.1s the baby having
diarrhoea?
15.1s there blood in baby's
stools?
•
In each of the follow up visits kindly mark the following either
through questioning or through observations
If there is affirmation of problem then mark (V) and if NO then mark
(X). If you notice any one of the symptom/ problem, then think that
there may be any infection and immediately refer to the nearest
PHC or other health centres.
Instruct the care takers on first aid if needed. If the child's body
temperature is cold (lesser than 36.5 degree Celsius) instruct
the how the child can be kept warm by skin to skin contact with
mothers body. Also suggest on the need to keep the baby warm
en route to hospital
16.1s the baby in-active?
17.Are the baby's eyes
swollen and discharging pus?
18.
19.Are the baby's skin folds in
arms and thighs red?
20.Does the child have boils
filled with pus?
S.Record her temperature in
Celsius.
•
If the temperature >37.5 degrees Celsius, administer the first dose of
paracetamol and refer to a health facility
4. Are her breasts hard/
nipples hard or broken/
experiencing pain in the
breasts or the nipples?
•
If YES, counsel her on right positioning and attachment of baby to the
breasts, before referring to a health facility
22.1s the baby not crying at
all or has a feeble cry?
23.1s the baby's tummy
bloated/ distended?
5. Does she experience
difficulty in breathing?
6.1s her uterus soft and
does she have excessive
bleeding?
21.
24.1s the baby vomiting?
•
If YES, provide uterine massage and advise breastfeeding before
referring to a health facility
25.Does the baby have
difficulty in breathing and
chest in-drawing?
26.1s the baby breastfeeding
7.Does she have pain
and foul-smelling lochia
discharge from the vagina?
poorly.
27.1s there redness or pus at
the cord stump?
8.1s she experiencing fits?
9.1s she experiencing severe
abdominal pain?
lO.Does she have burning
micturition?
•
If YES, advise more fluids before referring to health facility
42 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Design, Planning and Implementation of the Sukshema Project 43
Home visit number
I
4
28.# of full meals (and drinks)
she had in the past 24 hours.
If <3, discuss with her the
reasons, and advise her or
link her to other schemes/
facilities as required.
•
•
•
•
•
29.Does the mother avoid
any food and fluids? If YES,
counsel her on balanced diet
•
•
•
30.# of times the baby
breastfed in the past 24
hours. If <7-8 times, advise
her on the importance of
I breastfeeding discuss the
reasons and advise her
accordingly.
•
31 .Is she feeding the baby
anything other than breast
milk, including water, honey,
sugar etc.?
•
- 32.Has something been
applied to the cord stump?
33.1s the baby kept warm?
•
•
5
!
4O.CIeaning/bathing the baby
•
Give the following instruction during counselling: Do not give
bath to baby for the first two days. If it's necessary in summer give
sponge bath. During winter do noteven give sponge bath
41 .Care for baby's eyes and
ears
•
Make it very clear during counselling that nothing should be
applied or no drops be put without doctors' advice
6
Enquire how frequently in a day the nursing mother takes full meals
Educate on the importance of intake of nutrition food by the
nursing mother
If the nursing mother is taking food less than thrice a day , enquire
the reason and counsel on the same
If there any lack of finance for availing nutrition food, ensure that
they receive support from VHNSC or other organisations
Give attention in this regard in every visit
Nursing mother should intake have both solid and liquid from time
to time. Enquire about the same and educate on the importance of
doing so.
If you observe non adherence , discuss the reasons and deliberate
on the same with mother and family members
Give attention in this regard in every visit
a. Fever
b. Convulsions
c
O)
'«n
_g
2
o
ro
S
N
c. Blurred vision/severe
headache________________
d. Increased bleeding
e. Foul discharge or odour
f. Breathing difficulty
g. Swollen/ red/ tender
breasts
h. Pain/ difficulty in
passing urine
i. Worsening abdominal pain
Discuss how many times in a day the mother is breast feeding the
baby
If it is lesser than 7-8 times per day, discuss the reasons and educate
on the importance breast feeding and motivate them increase the
frequency. Suggest according to the problems they have.
Give attention in this regard in every visit
j. Worsening perineal pain
a. Breathing difficulty
b. Feeding problems
c. Convulsions
•
Explain the importance of breast feeding. Stress on the fact that
nothing else should be given other than breast milk
Give attention in this regard in every visit
d. Diarrhoea/vomiting
c
O)
a>
•
•
Examine if anything is been applied on the umbilical cord
Let them be known about the problems arising out of applying oil
or other things
Ensure nothing is applied / motivate not to
Give attention in this regard in every visit
•
•
•
Check if the baby is been kept warm during your visit
If NOT discuss the reasons and advice appropriately
Give attention in this regard in every visit
•
•
34. Has the baby been given
BCG?____________________
e. Hypo/hyperthermia
’w
g>
_g
c
o
Iz
co
f. Icterus/ yellow skin
g. Stiff (body arched) or
sloppy
h. lrritability/ lethargy
i. Pustules on skin or boil
j. Not passing urine at
least 6 times a day
k. Pus/ inflamed red
umbilicus
I.Blood in stool
35. Has the baby been given
44.Childhood immunizations
Polio 0?
45. Breastfeeding - right
positioning and attachment of
the baby to the breast
36.Has the baby been given
Hep B 0?
46. Breastfeeding - exclusive
breastfeeding
PNC home visit number
38.Keeping the baby warm
1
3
2
|
4
|
5
6
47.Breastfeeding - timely
complementary feeding
39.Cord care
a/th:
mint
Kit
Def'
planrf
'nd Irr ' nenta"'
of the ~ ' them- ~ -'ject
4
ANNEXURE3ASHA Reminder Cards
48. Nutrition - increased
calorie uptake, iron
supplementation and plenty
to drink
49. Counselling on care of
the newborn during ARI/
breathing problems/fever
50. Counselling on care of the
newborn during diarrhoea
and vomiting
PREPARATION FOR DELIVERY
51 .Family planning
Consiune HUlritious ^1
food at least four or
g
fivgjimesuQji day
i
r. gEgERRAL^.
52.Woman/child referred to a
health facility?
'1^ J Registration of name
53.Facility referred to
i Urine
54.Reasons for referral
test
55.Next follow-up visit date
(dd/mm/yy)
Avoid strenuous
work
■■■
Blood test
■
\
^/tfr
■■
[
I
46 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Consume Iron tablets
-“1
Design, Planning and Implementation of the Sukshema Project 47
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turning yellow in color
NEWBORN CARE
Redness of skin
Newborn cure
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and legs
ll .ll" I
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,.
51
Contraction!
of ribs (
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Breastfeed 8 to 10 times.
Lads of crying/
feeble cries
Xg-t Swollen
24
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54 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
i
2^
Clean the breast before
breast feeding
its
Design, Planning and Implementation of the Sukshema Project 55
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IMPORTANCE OF HOSPITAL DELIVERY
Why like this?
Home delivery
IMPORTANCE OF HOSPITAL DELIVERY
Let it be like this
Hospital delivery
ted
Rusted blade or scissors
Hands could be dirty in home delivery
In a hospital delivery hands are covered with gloves
-
Dirty cloth
Tying the umbilical cord with dirty thread
58 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Sanitized blade and scissors
Clean thread
Tying the umbilical cord with clean thread
Design, Planning and Implementation of the Sukshema Project 59
FAMILY PLANNING
Follow the right way of
breast feeding
Baby should sleep
next to mother
jfc;
Family planning
'
Severe blood loss
■•
Difference of three year
between the first child
and the second child
Baby should be wrapped
and kept warm
/
Kangaroo care
Do not apply anything
on the umbilical cord
Cleaning the
©fef® new born with
a clean cloth
without giving
a bath
' -h
Do not apply >
anything into I
the eyes and I
i ears of the f
baby
c ___
. Operation [male]
Condoms
Mala D tabh
il
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-23
Operation [ female]
0
Copper T
Vaccination to
' be given as per
the advice of the
doctor
r*' j
A baby girl is thq§
‘ light of the family]
With appropriate
care the infant can be
saved from risk
Vaccinations
5 C<
nrty
Intel
sns t
orov
ater
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>dd
'eaitl
■ainir.
I Kit
3
Birth spacing important
whether it’s a boy or a girl
De
Plan
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-nent
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yject
SEVEN
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
SUPPORTIVE
COMMUNITY MONITORING
ACKNOWLEDGEMENTS
Community Level Interventions for
The following institutions and individuals contributed
to the idea, design, writing and editing of this tool kit:
Improving Maternal, Neonatal and
Child Health: Supportive Community
Monitoring is the last module of the
tool kit in a series of seven on enhancing
community engagement for improving
outreach, shaping demand and
strengthening accountability to improve
maternal, neonatal and child health
outcomes in Karnataka.
Karnataka Health Promotion Trust (KHPT)
University of Manitoba (UOM)
Mr. Mohan H.L.UOM
Ms. Mallika Tharakan, KHPT
Ms. Prathibha Rai, KHPT
Mr. Nagaraj Ramaiah, KHPT
Mr. Somashekar Hawaldar, KHPT
Mr. KV Balasubramanya, KHPT
Dr. Suresh Chitrapu, KHPT
Mr. Manjunath S Dodawad, KHPT
Mr. Nirupadi Araliganura, KHPT
Mr. Pramod Kumar, KHPT
Mr. Parashuram Hiremane, KHPT
Ms. Rekha Basapura, KHPT
Mr. Srikanth Bannigola, KHPT
Mr. Revappa Belamalag
Khajavalli, KHPT
Mr. Basavanta Kamble, VHSNC President, Mudhol
taluk, Bagalkot
Mr. Mehaboob Saab, VHSNC President, Bilgi Taluk,
Bagalkot
Mr. Bavasavaraj, VHSNC President, Gangavati Taluk,
Koppal
Mr. Nagaraj Totad, VHSNC President, Koppal Taluk,
Koppal
Community Level Interventions
For Improving Maternal, Neonatal
And Child Health: A Training Tool Kit
SUPPORTIVE
COMMUNITY MONITORING
The National Rural Health Mission of Karnataka State,
the Department of Health and Family Welfare,
Karnataka State, Department of Women and Child,
Karnataka State and the Panchayats of Koppal and
Bagalkot districts supported this initiative.
Publisher:
Karnataka Health Promotion Trust
IT/ BT Park, 4th & Sth Floor
# 1-4, Rajajinagar Industrial Area
Behind KSSIDC Administrative Office
Rajajinagar, Bangalore- 560 004
Karnataka, India
Phone: 91-8(M0400200
Fax: 91-80-40400300
www.khpt.org
The following individuals from the Department of
Health helped us in our efforts:
Mission Director, NRHM
DHO, Koppal & Bagalkot districts
RCHO, Koppal & Bagalkot districts
DPMO, Koppal & Bagalkot districts
All the taluk coordinators, resource persons, medical
officers and all the front line workers in Koppal and
Bagalkot Districts contributed to the process of
developing, piloting and rolling out the training module.
Year of Publication: 2014
Copyright: KHPT
THE EDITORIAL TEAM:
Mr. H.L Mohan, KHPT
Ms. Mallika Biddappa, KHPT
Mr. Somashekar Hawaldar, KHPT
Ms. Dorothy L. Southern, KHPT Consultant
This manual is published with the support from the Bill &
Melinda Gates Foundation under Project Sukshema. The
views expressed herein do not necessarily reflect those of
the Foundation.
The photographs are by KV Balasubramanya.
They have been used in the module with consent from
the community.
^B^ukshema
Improved Maternal, Newborn & Child Health
ofr
1!WJ?
Ken
HW WR
The Community Level Interventions Training Tool Kit is a series of seven modules:
Module 1: Design, Planning and Implementation of the Sukshema Project
Module 2: Core Concepts of Maternal, Neonatal and Child Health
Module 3: Sukshema's Community Level Interventions
Module 4: Communication and Collaborative Skills for Front Line Health Workers
Module 5: Improving the Enumeration and Tracking Process
,
Module 6; Home Base Maternal and Newborn Care
Module 7: Supportive Community Monitoring
Module 7: Supportive Community Monitoring (SCM) aims to develop the
capacity of the members of the Village Health and Sanitation Nutrition Committee
(VHSNC). These members are tasked with providing support to the front line
health workers (FLWs) in their village, monitor service access and delivery, as
well as participate and share responsibility to improve the Maternal Neonatal
and Child Health (MNCH) outcomes and general health status of their village.
The module is intended to help the VHSNC Members understand the concept
of supportive community monitoring as opposed to authoritative supervision.
It aims to help VHSNC representatives engage the community in planning and
monitoring health service delivery to enhance the availability, accessibility, quality
and use of the public health system. Through the formation of a smaller group
of active Supportive Community Monitoring (SCM) Members who are trained
to carry out specific roles and responsibilities, this can be achieved. These. SCM
Members will be trained to use a SCM Tool that allows them to conduct a regular
joint reflection process, leading to community monitoring and evaluation of health
delivery systems on the ground.
ACRONYMS
6
Getting Started: The Doorway to Successful Training
7
SESSIONS
Session 1: Sharing knowledge and purpose
8
Session 2: Critical MNCH issues
9
Session 3: Understanding the importance of the SCM Team
11
Session 4: Modalities, role and responsibilities of the SCM Team
12
Session 5: Understanding the SCM Tool
14
Session 6: Selection of a SCM Team convener
16
Session 7: Responsibilities of the SCM Team Members
17
Session 8: Drawing up a SCM Team action plan
18
Session 9: Quiz and training evaluation and feedback
20
ANNEXURES
Annexure 1: SCM Tool
22
Annexure 2: Quiz questions for Session 9
30
&
ACRONYMS
ANC
ARI
ARS
ASHA
AWW
BCC
BP
BPL
,'r CBO
CDL
CMR
DOH
EDD
FLW
FP
GoK
HBMNC
IEC
IFA
IMR
IPC
JHA
JSY
JHA
KHPT
MDG
MMR
MNCH
NGO
NRHM
PHC
PNC
PRI
RP
SBA
SC
SC/ ST
SCM
,4 SCMT
SHG
TBA
VHW
VHSNC
.>:
Ante Natal Care
Acute Respiratory Infection
Arogya Raksha Samitis
Accredited Social Health Activist
Anganwadi Worker
Behaviour Change Communication
Blood Pressure
Below Poverty Line
Community Based Organization
Community Demand List (CDL1) Tool
Child mortality rate
Department of Health
Expected Date of Delivery
Frontline Health Worker
Family Planning
Government of Karnataka
Home Based Maternal Newborn Care
Information, Education, Communication
Iron and Folic Acid
Infant Mortality Rate
Inter Personal Communication
Junior Female Health Assistant
Janani Suraksha Yojana
Junior Female Health Assistant
Karnataka Health Promotion Trust
UN Millennium Development Goals
Maternal Mortality Rate
Maternal, Newborn and Child Health
Non-Government Organization
National Rural Health Mission
Primary Health Centre
Post-natal Care
Panchayat Raj Institution
Resource Person
Skilled Birth Attendant
Sub Centre
Scheduled Caste/ Scheduled Tribe
Supportive Community Monitoring
Supportive Community Monitoring Team/Tool
Self-help group
Trained / Traditional Birth Attendant
Tetanus Toxoid
Village Health Worker
Village Health and Sanitation Nutrition Committee
.
The Doorway to Successful Training in
Part 11 of Module 1 should always be
used to start a training workshop: initially
if covering all modules at one time, or
as a refresher if modules are scheduled
over a period ol lime. Ihe Doorway to
Successful Training contains a detailed
plan of sessions that sets the stage for the
workshop activities and logistics, covering
welcome, introductions, objectives, hopes
and fears, and ground rules.
6
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
■f /■
•'
..
© Objective
• To help the Village Health and Sanitation
and Nutrition Committee (VHSNC) Members
understand that training needs to be transferred to
others and they must be prepared to speak up and
share their knowledge.
Storytelling and discussion
(3)
Duration
30 minutes
Training Materials
Copy of story of the three dolls
df
Tips for facilitators
During the course of the discussion, do not enforce
the need to be a doll worth Rs. 15 on everybody. Be
open to listening to their choices.
O
Process
• Tell the participants the following story of
‘The Three Dolls’
A family of three, Mallappa (Father), Mahadevi
(Mother) and Suchithra (daughter) who lived in a
village went to the neighbouring village to attend a
fair. First they visited the temple and then went to
the fair to get something to eat. The daughter saw
some dolls on sale and pestered her parents to buy
her one. The father went to the shop selling dolls
and asked 'How much?’for a doll. The salesman
showed him three similar dolls and quoted prices of
Rs. 5, Rs. 10 and Rs. 15. The father then asked the
salesman, ’’Why are you quoting different prices
for the dolls that are so similar to each other?” The
salesman replied, "Sir, the dolls may look similar,
but they have different personalities”. So the father
asked him, "Please explain the personality ofthe
dolls to me”. The salesman took a thin string and
8
put it through one ear of the Rs. 5 doll and it came out
the other ear. He then put a thin string through the ear
ofthe Rs. 10 doll and it did not come out at all. He then
put the string through the ear of the Rs. 15 doll and it
came out of the doll’s mouth. Thefather decided to buy
the doll worth Rs 15.
• Ask the participants why they think the father bought
the Rs. 15 doll.
• Note their responses on a flip chart.
• Ask them which doll they would prefer and why.
• Allow several participants to share their choices and
reasons.
• Note their responses on a flip chart.
• Highlight any responses that focus on the different
types of people who make up any community. For
example, some people hear things, but it goes in
one ear and immediately out the other; they don’t
really listen. Others listen to everything, but never
say anything out loud to others. Still others listen
carefully and then speak up, which makes for an
interesting personality.
• Ask the participants if there were dolls for sale, how
much would they be worth? The answers might be
Rs. 15.
• Consolidate the session:
- Participants need to open up, talk and participate
freely in the training.
- Learning from this training needs to be transferred
to others.
- When they return to their respective villages, they
should tell their colleagues and friends about what
they learnt from the other VHSNC Members.
Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Objective
• To help participants understand the seriousness
of the MNCH situation in India as a whole and in
Karnataka State.
• To help them understand the deep causes of high
MMR and IMR.
Methodology
Storytelling and discussion
0
Duration
1 hour
Training Materials
Chart paper, marker pens and pre-prepared information
chart with details about the IMR and MMR, reasons
for deaths and other important aspects of the MNCH
continuum of care.
401
Process
• Tell the participants the following story of ‘
Kythamaranahalli:
SESSION 2:
CRITICAL
MNCH ISSUES
SHARING
KNOWLEDGE
AND PURPOSE
Methodology
O
Tips for facilitators
The main focus of this session is to help the VHSNC
Members think deeply about MNCH issues. Most
of them associate high MMR and IMR with medical
reasons and overlook the social causes that manifest
in the form of negative attitudes/ myths and harmful
cultural practices.
Doddegowda and his wife Gowdashyani lived in
Kythamaranahalli village. Doddegowda was the village
headfor his and 10 other neighbouring villages. His
was the last word in all these villages. His only worry
was that he did not have any children even after 8 years
of marriage. He had taken vows to please several gods
and finally he was blessed with a son whom he named
Ramegowda. Years went by and Ramegowda grew up
to be a fine young man. His parents got ready to find
a suitable partnerfor him so he could marry. When
he was 16 years old and studying in the 10th standard
his parents decided to marry him to a younger cousin
of his, Ramakka. She came from a goodfamily, which
meant that the alliance was immediately sealed.
This news of the planned marriage reached the local
ASHA. She requested Doddegowda and Gowdashyani
to postpone/stop the marriage since the girl was
very young. However, she. was angrily rebuffed by
Doddegowda. The ASHA, along with the Anganwadi
teacher and other officials, did not want to give up,
so they continued to make attempts to convince the
parents not to marry the young children. Their pleas
fall on deaf ears.
As planned Doddegowda celebrated the marriage ofhis
son and with god’s blessings Ramakka became pregnant
within 3 months. The ASHA visited their house as
soon as she heard about Ramakka’s pregnancy to
enquire about her wellbeing and give her information.
Ramegowdas father, Doddegowda did not think the
ASHA had the knowledge to guide his daughter-in-law.
So he didn’t listen to her and sent her on her way. This
happened again during her second visit. After that the
ASHA did not visit their house again.
Meanwhile, the Ramakka’s parents visited them to take
their daughter home for the delivery as is the usual
practice. When they arrived Ramegowda’s parents told
the in-laws that Ramakka is like a daughter to them
and that they would like to have her there when she
delivers her first child. They mention that there are no
amenities in the parent’s village. So Doddegowda told
the in-laws to go home and he promised to have the
delivery done at the village hospital. So the in-laws left
Ramakka with her husband’s family. Ramegowda is
unable to speak in front of his parents, so he sat there
as a mute spectator. As the date of delivery drew near
there was a discussion regarding the pregnant woman
Supportive Community Monitoring
9
delivering her child at the hospital. Then talk veered
to thefact that all the 12 deliveries in the past were
conducted by the family mid-wife at their own home
and that the mid-wife had proved to be lucky to the
family. So Doddegowda and Gowdashyani decided that
this delivery would also happen at their home with the
assistance of the mid-wife Rangamma.
Ramakka wanted to have a hospital delivery. But
what could she do? As her opinionated in-laws
wouldn’t listen to her parents, she decided to simply
trust god and stay silent. Ramakka's pains begin and
when the pain became unbearable thefamily sentfor
Rangamma, the mid wife. A ghee lamp was lit in front
of thefamily deity and Rangamma assured everyone
that everything was fine. But soon she told everyone
that the baby’s head was facing the wrong way and this
was thefirst time she had seen this happen. She said she
was not capable ofhelping Ramakka and to take her to
the doctor to at least save the life of the mother. After a
lot of searching the family located some transport and
managed to take the pregnant woman to the hospital.
It was 4pm when they finally reached the hospital. The
doctor had just left the hospital to catch a bus home.
The resident nurse there advised the family to take the
pregnant woman to the Taluk hospital. By the time they
reached the Taluk hospital it was 7.30 in the evening.
The doctor there, said that only one life could be. saved,
either the mother or the child, and the family decided to
save the life of the mother.
■ i' ■
• Divide the participants into four groups. Ask them to
discuss the following questions:
- What are the 4 major incidents in the story?
- Have similar incidents taken place in your village?
- Who plays the main roles in the story?
- Why did the death happen?
- Could it have been stopped?
- At what different times could the baby’s death been
avoided?
- Who are the individuals who could have stopped
this death?
- Who took the decision of whether the mother’s life
should be saved or that of the child? Why?
- What did the mother feel at that juncture?
- Did anyone at that point of time try to understand
her feelings?
- What might have been her decision?
- If that child could talk what would it have said?
• Allow 20 minutes for discussion, than ask a
representative from each group to take 5 minutes to
share the main points of their discussion.
• Encourage other groups to share any other key
information.
• Continue with the next 3 groups in the same manner.
• Use the pre prepared chart to highlight the current
situation of maternal and child health in India as a
whole and in Karnataka State.
• Consolidate the following points:
- The MMR and IMR in India and in Karnataka State
are very high.
- The reasons behind the high MMR and IMR are
linked to negative effects of social practices such as
child marriage and gender inequity.
•'-? ’ • w
V
Process
SESSION 3:
UNDERSTANDING
THE IMPORTANCE OF
THE SCM TEAM
Objective
• To help participants understand the need and
relevance of the Supportive Community Monitoring
SCM Team
•Jjf'
Methodology
Storytelling and discussion
Q
Duration
1 hour
Training Materials
Chart paper and marker pens
Q
Tips for facilitators
This session is a critical one as VHSNC Members may
have questions about their roles and responsibilities.
Even if they are not a member of the smaller SCM
Team, all VHSNC Members need to understand their
role is significant in improving the delivery and access
of the MNCH continuum of care services. If there
is any confusion, reassure them that the following
sessions will provide clarity about the SCM Team and
SCM Tool.
• Tell the participants that in Session 2 they heard a
story about the causes of maternal and infant deaths
and the seriousness of the issue. Now they need to
explore the possible solutions to address the causes.
• Tell them the following story.
A farmer in a village reared a cow and took it to his
field every dayfor grazing. A few months later the cow
delivered a calf and so the farmer kept the cow tied in
the cowshed and brought grass for it from the field so
it could get enough rest. A few days later thefarmer
wanted to begin taking the cow out to the field so that it
could freely graze as much as it needed. When he tried
to do so, the cow would take a few steps forward and
then come running back to the cowshed. No amount of
goading by the farmer and his family members changed
the behaviour of the cow.
• Ask the participants why the cow wasn’t ready to go
to the field.
• Note their responses on a flip chart.
• Continue with the story:
One day when thefarmer returned after working in
the town, he was pleasantly surprised to see his cow
grazing in thefield with its calf.
• Ask the participants what might have made the cow
decide to return to the field.
• How do they think the calf found its way to the field?
• Note their responses on a flip chart.
• Continue with the story:
lhe farmer's 8 year old daughter saw that her father
was unhappy with the situation so she had devised a
plan. She had seen herfather milk the cow and leave
the milk at the doorstep. So that morning, the girl
dipped her little finger in the milk and held it near the
calf’s mouth. 'Ihe calf began to suckle at herfingers.
The girl continued to do this for a couple of days and
the calfbecome used to this. On the third morning she
dipped her fingers in the milk, and started walking to
the field, stretching out her fingers to the calf. It soon
followed her to the field.
• Ask the participants who the farmer represents in this
story.
• Note their responses on a flip chart.
• Highlight any answers that focus on the role of
provision of health service, such as a doctor, JHA or
the ASHA.
• Tell the participants that in the story the farmer
Supportive Community Monitoring 11
represents the health department, the cow represents
the community, the calf represents the VHSNC, the
daughter is the SCM Team, the little finger represents
the SCM Tool and the field represents the MNCH
continuum of care services.
• Discuss these roles in detail with all the participants.
- What services are extended by the health
department to the community?
- Are community members accessing all these
services?
• Tell the participants that even though the health
department (the farmer) extends a range of services
through the ASHA and JHA, and despite repeated
requests by doctors to come to the hospital for a
check-up, undergo a HIV test, or take iron tablets, we
do not access the services (like the cow).
• Ask the participants to tell you what they know about
the VHSNC and its role.
• Note their responses on a flip chart.
• Tell the participants that as VHSNC Members they
should come together to discuss any issues at the
village level.
• Tell the participants that the SCM Team is a small
team within the VHSNC that is assigned to provide
support and to monitor the delivery and access of
MNCH continuum of care services at the village level.
Just like the girls fingers in the story, the SCM Team
has access to a tool to carry out this responsibility in
an effective way.
• Consolidate the session:
- The SCM Team is necessary and relevant.
- In order to streamline the activities, this smaller
team, comprising of 6 members, will be formed
within the VHSNC that will take the lead in using
the SCM Tool every month.
SESSION 4:
t MODALITIES,
ROLE AND
RESPONSIBILITIES OF
THE SCM TEAM
• To clarify the modalities, role and responsibilities of
the SCM Team
■Jyf
CB
LIST OF ROLES AND RESPONSIBILITIES
OF THE SCM TEAM MEMBERS
Role and responsibilities of the ASHA worker:
1. Extend MNCH services, such as TT
injections, iron tablets and vaccines for babies
in the commtmity.
2. Provide information regarding critical
symptoms during house visits and follow-up
with each of the MNCH continuum of care
• cases, i,e., ANC, Delivery and PNC.
3, Organize the monthly meeting of the VHSNC.
tv
Objective
Methodology
Duration
Rain claps game and discussion
1 hour
Tips for facilitators
This session is critical in order to help the members
understand the vision and purpose of the SCM Team.
If they have questions related to how they would
carry out their responsibilities, assure them that the
next session will clarify that.
club member to stand up and continue to clap with 4
fingers. Then ask a person interested in mother and
child health to stand up and continue to clap with 5
fingers. Finally ask the President of the VHSNC to
stand up and clap with both hands.
• When all 6 members are now standing up, explain
that this 6 member group is called the Supportive
Community Monitoring Team (SCM Team).
This team will try to strengthen and motivate the
remaining VHSNC Members to assess, support and
monitor the MNCH service delivery system in the
village.
• Ask the SCM Team to brainstorm the roles and
responsibilities for its members.
• Note their responses on a flip chart.
• When all points have been noted, share the list below
for discussion.
• Tell the participants that in addition to the points
listed, the SCM Team will be conducting a monthly
assessment and self-reflection exercise using the
SCM Tool to understand the status of MNCH service
delivery in their village.
Process
• Tell the participants to play the ‘rain claps’ game.
• Tell each participant to clap with one finger (strike
with one finger - index finger of one hand on the
palm of other hand).
• Then ask them to use 2, 3,4 and 5 fingers, and finally
use the entire hand to clap.
• Ask the group to explain the difference between
clapping with one finger and clapping with the entire
hand.
• Note their responses on a flip chart.
• Now ask an ASHA to stand up and to continue to clap
with one finger. Next, ask a self-help group (SHG)
member to stand up and to continue to clap with 2
fingers. Then ask an SC/ST woman to stand up and to
continue to clap with three fingers. Next ask a youth
12 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Role and responsibilities ofthe SHG Member:
1. Create awareness about MNCH services with
any pregnant woman, recently delivered and
nursing mother living in the same lane or
road as the member.
2. Utilize a portion of the VHSNCs untied fund
towards improving MNCH services.
3. Take preventive measures against child
marriages. ■
4. Raise a voice against discriminative, ignorant
and repressive practices prevalent in the
village.
Role and responsibilities of the SC/ST Member:
1. Ensure that the children living in the same
lane or road as the member are all vaccinated.
2. Ensure that all child deliveries are conducted
3.
4.
at the hospital by linking the beneficiaries.
Convey health related information to the
community.
Ensure that the beneficiaries come forward to
access the services offered.
Role and responsibilities of the Youth Club
Member:
1. Donate blood to pregnant women delivering a
child when required.
2. Accompany or send critical patients to the
hospital.
3. Help the people understand the importance of
maintaining cleanliness in the village.
4. Support actions to prevent child marriages
such as informing higher authorities about
potential offenders.
Role and responsibilities of the person interested in
mother and child health:
1. Inform the community about the advantages of
nutritious food.
2. Inform the community about the advantages of
health and cleanliness.
3. Support the prevention of child marriage.
4. Keep track of the health status of pregnant
women and nursing mothers.
5. Help resolve conflicts and problems within the
community around health issues.
Role and responsibilities of the VHSNC president:
1. Ensure that the services due to the community
’
are extended to them.
2. Ensure that cleanliness is maintained in the
village.
3. Take preventive steps to stop the spread of
contagious diseases.
4. Organize and preside over the monthly
VHSNC meetings.
5. Ensure that the VHSNC untied funds are
utilized for the benefit of mothers and children.
• Consolidate the session:
- Participants are aware of the role and
responsibilities of the SCM Team.
- Participants are motivated to work together
to improve the MNCH continuum of care
services.
Supportive Community Monitoring 13
X -’OS
SESSION 5:
UNDERSTANDING
THESCMTOOL
STAGE 1 - IN-DEPTH STUDY OF THE
SCM TOOL
Objective
• To introduce and explain in detail the SCM Tool to
all the participants.
• To ensure participants have practical experience in
using the SCM Tool and in analyzing its findings.
Methodology
Reading, discussion, group work
©
Duration
2 hours
Training Materials
Copies of the SCM Tool (Annexure 1), chart paper
and markers
Q Tips for facilitators
Give the participants examples of villages where
members of the SCMT have played a very active role
in promoting MNCH services. For example ensuring
that families listen to the instructions given by an
ASHA or that poor pregnant women are taken to
institutions for delivery using money from the untied
funds to support their transportation costs. The
groups may take a while to grasp how to fill in the
tool and then how to use it. Be patient and explain
again until everyone has thoroughly understood it.
O
Process
• Distribute copies of the SCM Tool to each of the
participants (Annexure 1).
• Read and review all the information.
• Ask the participants to share their views about the
SCM Tool.
• Note their responses on a flip chart.
• Highlight and discuss the following points:
- It helps to provide space for VHSNC Members to
understand, assess and monitor health situations.
- It helps to evolve local and joint solutions for
MNCH issues and to supports efforts of FLWs.
- It helps to enhance accountability and sustainability
of health activities at village level.
• Tell them that the SCM Tool will support them as a
team to assess the status of MNCH service delivery
and access in their villages.
STAGE 2 - USING THE SCM TOOL
O
Process
• Divide the participants into four groups. Give them
one section of the SCM Tool.
• Ask them to read and discuss their section and
answer the following questions:
- What is the main focus?
- What are the main points?
- How will the SCM Team Members gather the
required information?
- How will this information help the SCM Team
Members?
• Allow 20 minutes for discussion, then ask a
representative from each group to take 5 minutes to
share their answers.
• Ask the other groups to share any other key
information about that section.
14 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
• Continue with the next 3 groups in the same manner.
• Now ask the groups to enact an interaction with
individuals as instructed in the SCM Tool. For
example:
- Group 1 needs to carry out discussions with the
ASHA in the village and fill in the Tool.
- Group 2 needs to conduct discussions with AWWs
in the village and fill in the Toot
- Group 3 needs to have a discussion with the VHSNC
Members and fill in the Tool.
- Group 4 needs to carry out general enquiries and fill
in the Tool.
• Make sure that everyone has read and understood the
scoring process and the consolidation table and that
everyone know how to fill that section in.
• Assist each of the 4 groups to analyze the outcome of
the interactions.
• Assist them in scoring the status of the village.
• Tell them that when they do this exercise every
month, they will be able to see whether the village
is making progress on the tools indicators, or not.
This will help them to know what kind of corrective
measure is needed and when to take action.
• Consolidate the session:
- The SMC Tool is a mirror of the MNCH status of
the village. After using the SMC Tool each month,
the data can be analyzed to either highlight progress
or to note when progress is not being made and
additional activities need to be implemented.
- The SCM Tool is not intended to supervise or
identify gaps in service delivery of individual FLWs,
but to help the SCM Team and VHSNC Members
to understand their village and the issues around
MNCH and offer support to the FLWs in carrying
out their responsibilities.
- The SCM Tool is not a standalone exercise, but a
means to carry out a supportive monitoring role
focused on MNCH in the village on a regular basis.
■
-
-
.
'5: < •
1
J
BHMO -..
1
SESSION 6:
SELECTION OF A SCM
TEAM CONVENER
■
”......
l; I
I
LI t
Ad
B
■
LW’
*
SESSION?:
RESPONSIBILITIES
OF THE SCM TEAM
MEMBERS
___
Objective
• To help the participants understand the
importance of choosing an effective convener to
steer the SCM Team
Methodology
Storytelling and discussion
(Sy’
®
Duration
45 minutes
Training Materials
Chart paper and markers
d
Tips for facilitators
Ensure that the participants from each village work
together during this session so that they can engage
in discussions together and create a common
ownership of the intervention.
O
Process
• Ask the participants to sit with their own SCM
Team Members from their own village.
• Share the following story:
with the fact they had not set the boat free from its
moorings so it was still in shallow water. If they had
been in deeper water, they might have caught more
fish.
• Tell them that similarly VHSNC Members seemed
to have settled down in the comfortable chairs. They
have not taken any proactive steps to take the village
forward. The have hammered a stake to the ground
and tied themselves to it.
• Tell them that they need to identify a SCM Team
Convener who will take the lead in getting the group
together and keep everyone motivated.
• Divide the participants into 3 groups.
• Allow 15 minutes for each group to choose their SCM
Team Convener and then to introduce each person
chosen to the larger group.
• Consolidate the session:
- The SCM Team Convener is chosen by a team that
understands the importance of this role.
- The SCM Team Convener s role is to streamline
activities and ensure that the SCM Teams
responsibilities are carried out smoothly.
Two friends owned a boat. One day they went out
fishing and caught a lot offish. They moored the
boat near the dock and took all their catch to the
market, sold it, and earned lots of money. Overjoyed
by the windfall they decided to go back to fish again
to see if they could catch even morefish. When they
finally returned to the place where the boat was
moored, it was early in the morning, and the sun
was just rising. They began to pull in the fish nets
from the water, but unfortunately there was not a
single fish in the net.
• Ask the participants why the friends could not
catch a lot of fish the second time.
• Note their responses on a flip chart.
• Highlight any responses that link the poor catch
16 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
© Objective.
Process
• To ensure that SCM Team Members are clear
about their responsibilities and are committed to
fulfilling them
•jjF
Methodology
Duration
Group discussion
30 minutes
Training Materials
Chart paper and markers
o Tips for facilitators
Make sure that the SCM Team Members are not too
ambitious about planning activities. They need to be
realistic and practical.
• Ask the participants to sit with their own SCM Team
Members from their own village. Give them chart
paper and markers.
• Ask each team to discuss what kind of activities they
should conduct.
• Allow 20 minutes for discussion and then ask the
SCM Team Convener to display their activities in
front of the training room and share them.
• In plenary, check which of the activities are feasible or
realistic, or not
• Have each group decide on a list of possible activities
in a given timeframe.
• Tell the participants that the main responsibilities of
the SCM Team Members are:
- Conducting the monthly VHSNC and SCM Team
meetings
- Filling the SCM Tool every month and analyzing
it to keep track of the villages progress on MNCH
issues.
- Following-up on the necessary measures to put into
place based on the gaps identified with the SCM
Tool.
- Taking proactive steps to safeguard the health of the
villagers.
- Participating in the proceedings of the ‘Arogya
Mantapa’.
- Being involved in all the health related activities that
are implemented by the GoK Department of Health.
- Offering all needed support to the FLWs.
- Intervening when families refuse to admit a
pregnant woman for institutional delivery.
• Consolidate the session:
- A SCM Team’s role is more supportive in nature.
- It must not take on roles and responsibilities that
duplicate those of the FLWs.
Supportive Community Monitoring 17
SESSION 8:
ELECTING SOM TEAM
REPRESENTATIVES AND
DEVELOPING AN ACTION PLAN
Objective
O
• To help the SCM Team Members elect competent
representatives and develop a 1 year realistic
action plan.
Methodology
Discussion, voting, group work
(3)
Duration
1 hour and
15 minutes
Training Materials
Card sheet, chart paper and markers
Cfe
Tips for facilitators
Ensure that everyone is involved in the selection
process and that everyone knows the importance of
identifying the right individuals for the SCM Team
positions without any bias.
S.No
Process
• Ask the participants to sit with their own SCM Team
Members from their own village.
• Tell them to democratically select two of their group
members to be SCM Team Representatives: one male
and one female, but the ASHA is not allowed to be a
representative.
• When all groups have elected their new SCM Team
Representatives, introduce them in plenary.
• Allow 40 minutes for each team to develop a one year
action plan using the format below.
• Ask for both of the newly elected SCM Team
Representatives from each group to take 5 minutes to
share their action plans.
• Ask the other groups to give comments and
suggestions.
• Continue on with the other groups in the same
manor.
Responsibility and support
Ti-nelme
/
• Consolidate the session:
- When choosing a SCM Representative, priority
should be given to creative individuals and those
with leadership traits.
- Action plans must be based on facts and with
realistic timeline.
18 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
TRAINING EVALUATION AND FEEDBACK FORM:
SESSION 9:
QUIZ AND TRAINING
EVALUATION AND
FEEDBACK
KARNATAKA HEALTH PROMOTION TRUST
Training Evaluation and Feedback Form
S.No.
O
• To assess what affect the module had on the
participants' attitudes, knowledge and practice
levels.
• To obtain feedback from the participants on the
usefulness of the training and suggestions for
enhancing future effectiveness.
■Jjfr Methodology
Quiz and reflection
Duration
30 minutes
Training Materials
Quiz (Annexure 2), training evaluation and feedback form
CB
Tips for facilitators
The training evaluation and feedback form will assess
what affect the module had on the participants'
attitudes, knowledge and practice levels and obtain
feedback on the usefulness of the training and
suggestions for enhancing future effectiveness.
Process
• Ask the participants to sit with their own SCM Team
Members from their own village.
• Tell them that you will read out a question and if
any one of the SCM Team Members from any group
knows the answer they should shout it out. If correct,
that team gets a point
• The team with the most points wins the quiz.
• Ask the winning team to all stand up and be
congratulated!
!
• Distribute the training evaluation and feedback form.
Go over all the areas that the participants will need to
think about while filling it in.
• Allow 20 minutes to complete it.
• Collect the training evaluation and feedback forms
from the participants.
• Before the closing ceremony begins, ask the
participants to share their feelings about the training:
encourage anyone who is keen to orally share two
positive aspects and two areas that need improvement.
• At the closing ceremony thank all the participants for
their enthusiastic participation, congratulate them and
wish them the best as they go back to their own field
areas and begin to initiate the intervention on ground.
• Thank everyone else who contributed to the training
program. This might have included administrative
staff, venue owners, facilitators, guest speakers and the
organizers.
Name of the PHC:
Subject
Excellent
Good
Poor
Training content and sessions
1
J Training methodology and activities used
2
Objective
Place of training:
Designation:
Name:
Training dates:
3
i Training skills of the facilitators
4
j Logistics at the training (Food, stay and comfort)
5
i Relevance and usefulness of training
List the three aspects of the training that you found most useful.
1.
I
2.
3.
Name any session during the training that you did not understand properly/ or that was not
communicated well.
1.
2.
3.
What are the three most important lessons that you can take back to your work place from this training?
1.
E
I
>1
2.
3.
Please list suggestions for improved facilitation in future trainings.
1.
I
|
2.
3.
20 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Supportive Community Monitoring 21
■
--iA
ANNEXURE 1 - SCM Tool
Project Sukshema
PROCESS GUIDELINES FOR THE SUPPORTIVE
COMMUNITY MONITORING TOOL
Department of Health, Government of Karnataka
National Rural Health Mission
iJ
1. Constitution of the Committee - There will be 5
members nominated from the VHSNC
i. Chairperson of the VHSNC - Member of the
Gram Panchayath of that village, who will preside
over all meetings
ii. ASHA - Member Secretary
iii. Woman representative of the SC/ST community
iv. Member of the Self Help Group
v. Member of Youth Group
COMMUNITY SUPPORT MONITORING TOOL
Name of the village
Village code
Name of sub-center
Sub-center code
Name of the Primary
Health Center
PHC code
Taluk
District
NAMES OF THE MEMBERS OF THE SUPPORTIVE COMMUNITY MONITORING COMMITTEE
1
2
4
5
3
STEPS TO FIND OUT THE PERCENTAGE (% ) FOR EACH INDICATOR
• For every indicator there will be a target and achievement, for the month.
• Target indicates the number of women to be given service for each ASHA area.
• Achievement indicates the number given service for each ASHA area.
• Look up for the target and achievement in the abstract for ASHAs in ETT abstract.
• Each ASHA tells her Achievement and Target for her area.
• Add up the target and achievement for all ASHAs under that VHSNC.
• For example, there are four ASHAS under one VHSNC. Then target for that VHSNC= Targets of ASHA 1 + ASHA
2 + ASHA3 + ASHA4 . similarly Achievement for that VHSNC= Achievements of Al + A2+ A3 + A4.
• Divide the achievement by target, and multiply quotient by 100. (A/TxlOO). This gives the % for each indicator.
• If the achievement is 75% and above mark a ‘happy face’, if less than 75% mark ‘sad face
• There are certain indicators for which the answer could'be ‘yes’ or ‘no’. In such cases mark ‘happy face’ for ‘yes' and
‘sad face’ for ‘no’.
• In the last section of the tool “Significant Issues” if the answer is ‘no’ mark ‘happy face’ and if it is ‘yes’ mark ‘sad face’
22 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
2. There are four sections in this tool
i. Mother and child health
ii. Anganwadi Services
iii. VHSNC
iv. Other significant issues of the village
3. Process
• The Committee will monitor the issues in two groups
of 3 and 2 members each. One group will meet up
with the ASHAs of the village and discuss about the
ANC and PNC services rendered by them.
• The other group will discuss with anganwadi
workers about the services provided by them such as
nutrition, health education, mothers meeting, village
health and nutrition days.
1
• Based on the discussions the tool will be filled by each
group respectively and the consolidation done.
• The challenges or problems that emerge from the
discussion are classified under 3 categories - a. Family
based b. Social practices c. Systemic inadequacies
• Each group, based on the problems or challenges and
the reasons identified, will work out strategies and
action to be taken to address them.
• All 5 members of the SCMC will present their
discussion and feedback to the VHSNC, and also
discuss with the members on the village health issues
and the support given to the front line health workers.
• The VHSNC will also discuss other significant issues
such as child marriage, death of child/mother or
community member etc.
• The outputs of the discussion ofithe two groups and
the VHSNC are consolidated to arrive at the health
status of the village for the particular month.
The decisions taken and recommendations in the
VHSNC are presented at 3 levels at Sub-center level,
Panchayath and PHC and also for follow-up action.
Supportive Community Monitoring 23
SERVICE RELATED TO PREGNANT WOMEN, JUST DELIVERED MOTHERS AND
NEO-NATAL CHILDREN
Sl.No
1
2
(This is to be filled based on consolidation of the target and achievement abstract of ASHAs of the village. If
the achievement is above 75% of the target then mark the ‘happy face’, and if less mark the ‘unhappy face’ for
each indicator as explained in the previous session.
% of pregnant
women
registered
% of pregnant
women
received TT
%of
institutional
deliveries
5
6
K/iSlT
DETAILS OF THE ANGANAWADI SERVICES
SI.
No
1
% of PNC
visits
(completed)
2
3
4
% of pregnant
women
received IFA
% of pregnant
women
received ANC
services
7
8
% of children
immunizations
(% of children
immunized
0-11 months)
% of married
women
practicing
family
planning
3
Please fill in this page of the tool based on the discussions with
Anganwadi workers of the village
Source : Anganwadi Registers and Abstract of the ASHAs.
Please mark the ‘happy face’ if the answer is ‘yes’ or % is above 75%
% of mothers’
monthly meetings
4
%of children
under 3 yrs
weighed
5
% of malnourished
children under 3
yrs who received
nutritious food
Is the Village
Health and
Nutrition day
observed in the
month?
% of pregnant and
delivered mothers
received nutritious
food
Please count the total number of happy and unhappy
faces and fill in each box
Please count the total number of happy and unhappy
faces and fill in each box
PROBLEMS / CHALLENGES/ REASONS
PROBLEMS / CHALLENGES/ REASONS
DECISIONS TAKEN BASED ON THE DISCUSSIONS WITH ASHAS
DECISIONS TAKEN BASED ON THE DISCUSSIONS WITH ASHAS
24 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Grade
O O
e
Supportive Community Monitoring 25
SIGNIFICANT INFORMATION
INFORMATION ON VHSNCS PERFORMANCE
SI.
No
1
2
3
4
Please fill in this page based on the discussions with VHSNC members
Please mark the ‘happy face’ if the answer is ‘yes’ or else ‘unhappy face’, or % is above 75%
The number of ASHAs and AWWs together should be added and % collected
Testing and
purification of
the safe drinking
water sources
% of ASHAs
and AWWs
functioning in the
village?
5
%of ANM visits
to the village
Have the
immunization
programs been
organized
regularly?
Please count the total number of happy and unhappy
faces and fill in each box
6
Have the
pregnant women
and delivered
mothers been
given any support
by VHSNC
(nutritional,
monetary
for medicine
or vehicle
support) or has
the VHSNCs
supported
FLHWs?
Is the fogging
done regularly
to control
mosquitoe
SI.
No
1
Please fill in this page based on the discussions with VHSNC members
Please mark the ‘happy face’ if the answer is ‘yes’or eise ‘unhappy face’.
Iff
<£
Has there
been any child
marriage jn the
village?
2
Has any child
less than 1
yr / recently
delivered
mother fallen
sick and
hospitalized
seriously?
3
Has there been
any death of a
child below one
year?
4
Has there
been death
of a recently
delivered
mother reported
in the village?
5
Has there been
any death in
the community
reported, for
any other
reasons?
Please count the total number of happy and unhappy
faces and fill in each box
o O
e
PROBLEMS / CHALLENGES/ REASONS
PROBLEMS / CHALLENGES/ REASONS
DECISIONS TAKEN BASED ON THE DISCUSSIONS WITH ASHAS
ANALYSIS OF ALL THE SERVICES IN THE VILLAGE
DECISIONS TAKEN BASED ON THE DISCUSSIONS WITH ASHAS
ASHA Services rendered to mother and child
'o O
AWWs services
o O
©
a o
VHSNCs performance
26 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
Supportive Community Monitoring 27
MONTHLY CONSOLIDATIONS
SI.
No
Section
There are 24 questions in the tool. Add up the number of ‘happy faces’
and the number of ‘sad faces’ for all the 3 services.
1
If the number of‘happy faces’ exceeds 18, then mark ‘happy face’ for that month.
2
‘Happy faces’ are between 12-18, then mark the ‘poker face’
July
August
September
ASHA Services
2
ANGANAVADI
Services
November
December
o o
0 ©
o ©
1
October
9
©
o ©
o ©
©
‘Happy faces’ less than 12 then mark ‘sad face’
3
o ©
0 ©
3
Consolidated village health status for the month
Consolidation for the year
Consolidation for the year
Section
1
©
VHSNC
Performence
January
February
March
ASHA Services
April
May
June
Section
January
February
Health status of
VHSNC
0
March
April
May
June
October
November
December
©
© o
2
Section
ANGANAVADI
Services
July
'o O
Health status of
VHSNC
0 O
3
VHSNC
Performence
August
September
o o
0 o
'o ©
9
©
28 Community Level Interventions for Improving Maternal. Neonatal and Child Health: A Training Tool Kit
Supportive Community Monitoring 29
ANNEXURE2Quiz questions for Session 9
1.
How many members make up the SCM Team?
2.
From which committee have the SCM Team Members been chosen?
3.
Who are the 6 SCM Team Members?
4.
Who is the secretary of VHSNC?
5.
Who selects the ASHA?
6.
What do we mean by maternal mortality?
7.
What do we mean by child mortality?
8.
Who is the president of the VHSNC?
9.
What do we mean by a happy face?
10. How much funds does the NRHM transfer to the VHSNC?
11. How many fatal diseases attack children? Which are they?
12. Which is the legally marriageable age specified by the government?
13. In SCM Tool specify the one criterion that if it is classified as a weepy face
then the entire village is classified as a weepy face village?
14. Who are all responsible for health care?
15. In the Kyathamaranahalli story what character dies?
16. How much does the doll cost which listens through its ears and speaks
through its mouth?
17. What does “Our village healthy village” mean?
18. What does “NRHM” mean?
19. Which is more, 1 kg of iron or 1 kg of cotton?
20. Our district should be rid of---------- and-------
deaths
21. Describe the SCM Tool.
22. What is the color of the new born smiling teeth?
23. What do you mean by ASHA?
24. What is the total number of checkups for a pregnant woman?
25. What are the symptoms that indicate that a pregnant woman is in a
serious condition?
26. How many times does an ASHA visit a woman who has delivered a baby?
Give the days on which she visits?
27. What is the frequency of VHSNC meetings?
28. In how many districts is VHSNC present?
29. How many members make up the VHSNC?
30. Which are the tablets that a pregnant woman must take? How many?
30 Community Level Interventions for Improving Maternal, Neonatal and Child Health: A Training Tool Kit
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