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“Birth Preparedness and Complication Readiness”
of ASHAs under the safe motherhood intervention
programme of NRHM at Koppal, Karnataka
Dr. Smitha P.K
Dissertation submitted in partial fulfillment of the
requirement for the award of the degree of
Master of Public Health
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Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala
October 2011
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CERTIFICATE
Certified that the dissertation titled “Birth Preparedness and Complication
Readiness” of ASHAs under the safe motherhood intervention programme of
NRHM at Koppal, Karnataka is a bona fide record of original research work
undertaken by Dr. Smitha P.K in partial fulfillment of the requirements for
the award of the degree of‘Master of Public Health’ under my guidance and
supervision.
Dr T. K. Sundari Ravindran M.Sc., Ph.D.
Professor
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala
October 2011
DECLARATION
I declare that this dissertation is the result of my original field research. It
has not been submitted to any other university or institution for the award of
a degree. Information derived from the published or unpublished work of
others has been duly acknowledged in the text.
Dr Smitha P.K
Achutha Menon Centre for Health Science Studies
Sree Chitra Tirunal Institute for Medical Sciences and Technology
Thiruvananthapuram, Kerala
October 2011
DEDICATION
To my husband Rejeev, my son Rahul for their support, patience and
encouragement throughout my study period;
To my parents Omana and Kochukuttan for the value of education and
learning they instilled in me.
ACKNOWLEDGMENTS
I am grateful to God Almighty for giving me life and the strength to go through this course
successfully.
I would like to pass my heartfelt gratitude and appreciation to my guide Dr T.K Sundari
Ravindran for her unreserved assistance in all matters. Her encouragement, guidance and
support from the initial to the final level enabled me to build up an understanding of the subject.
This thesis would have not been as standardized as it is now without her great support.
I am grateful to Dr. P. Sankara Sarma for his support in designing the study and valuable
suggestions thereafter.
I am also very grateful Dr V.Raman Kutty, Dr. K.R Thankappan , Dr.Mala Ramanathan and all
other faculties who guided me with their valuable comments at various stages of this study.
I express my special thanks to Dr Mini G.K for her help during analysis of my data.
I gratefully acknowledge the valuable support provided by the NRHM, Karnataka to carry out
the study at Koppal. My sincere appreciation and thanks for the support of all the respondents,
for without them this report would not have been possible.
I thank and appreciate my mother and my sister Sneha for their patience during my period of
absence from home and for tirelessly taking care of my son during my absence.
I am very grateful to all my course mates especially, Dr Lipika, Dr Brajesh and Dr Ramona.
Many thanks also go for all my friends who have helped and encouraged me during my study,
as well as expressing my apology because I could not mention personally one by one.
TABLE OF CONTENTS
Abbreviations /Acronyms
List of tables
List of figures
List of appendices
Abstract
Page
CHAPTER ONE - INTRODUCTION
No.
1.1 Background of the study
1
1.2 Problem Statement
4
1.3 Research obj ectives
4
1.4 Rationale of the study
5
1.5 Conceptual framework
6
1.6 Organization of thesis report
7
CHAPTER TWO - LITERATURE REVIEW
2.1
Introduction
2.2 Defining birth preparedness and complication readiness
8
8
2.3 Evidence of CHWs in birth preparedness and complication readiness
2.3.1
Global scenario
9
2.3.2
Indian scenario
12
CHAPTER THREE - METHODOLOGY
3.1
Study design
15
3.2 Study setting
15
3.3 Sampling and sample techniques
15
3.3.1
Sample size
15
3.3.2
Sampling technique
15
3.3.3
Sample selection procedure
16
3.3.4
Selection criteria
16
3.4 Study variables
3.4.1
Operational definition of independent variables
17
3.4.2
Operational definition of dependent variables
18
3.5 Data collection techniques and tools
21
3.5.1
Development of the interview schedule
21
3.5.2
Pretesting
22
3.5.3
Data collection procedure
22
3.6 Data analysis
24
3.7 Ethical considerations
24
CHAPTER FOUR - RESULTS
4.1
Sample characteristics
25
4.1.1
Socio-demographic characteristics
25
4.1.2
Work related characteristics
26
4.2 Knowledge levels
4.2.1
4.2.2
Danger signs
31
a
Pregnancy
31
b
Labor and child birth
32
c
Labor and child birth
32
d
Score of Key Danger signs
32
Antenatal Care
a
Components of Antenatal care
33
b
Frequency and Timing of ANC checkups
35
c
Information provided during home visits
35
d
Birth preparedness plan
36
e
Score of birth preparedness plan
38
ii
4.2.3
Post partum Checkups and Advice
38
4.3 Service provision
4.3.1
Antenatal care
40
4.3.2
Birth preparedness
41
4.3.3
Provision of Emergency transport, Funds and Blood
42
4.4 Support mechanisms and barriers
45
4.5 Bivariate analysis
4.5.1
Factors associated with the knowledge scores of key danger signs.
4.5.2
Factors associated with the Knowledge scores of essential 55
54
components in ANC
4.5.3
Factors associated ANC service provision
4.5.4
Factors associated with provision of emergency transport, funds and 58
56
blood
CHAPTER FIVE - DISCUSSION AND POLICY RECOMMENDATION
5.1
Discussion
59
5.2 Strengths of the study
63
5.3 Limitations of the study
64
5.4 Policy recommendation
64
5.5 Conclusion
67
REFERENCES
68
iii
Abbreviations
ANC
Ante Natal Care
ANM
Auxiliary Nurse Midwife
ASHA
Accredited Social Health Activist
AWW
Anganwadi Worker
"BP
Birth Preparedness
BPL
Below Poverty Line
CHC
Community Health Centre
CR
Complication Readiness
CHW
Community Health Worker
DH
District Hospital
EDD
Expected date of delivery
EMoC
Emergency Obstetric care
Gol
Government of India
IFA
Iron Folic Acid
IPHS
Indian Public Health Standards
JSY
Janani Suraksha Yojana
JHIPEGO
John Hopkins Program for International Educate
in Gynecology and obstetrics
iv
MDG
Millennium Development Goal
MMR
Maternal Mortality Ratio
M/0
Medical Officer
NFHS
National Family Health Survey
NRHM
National Rural Health Mission
PHC
Primary Health Centre
PNC
Post Natal Care
PPH
Post Partum Hemorrhage
PPP
Public Private Partnership
RMP
Rural Medical Practitioner
SC
Sub Centre
TBA
Traditional Birth Attendant
TT
Tetanus Toxoid
UNFPA
United Nations Population Fund
UNICEF
United Nations Children’s Fund
VHND
Village Health and Nutrition Day
VHSC
Village Health and Sanitation Committee
WHO
World Health Organization
v
List of tables
Table
Content of the Table
No:
Page
No
1
Socio-demographic characteristics of the sample population
25
2
Work related characteristics of the sample population
28
3
30
6
Key danger signs during pregnancy, labor and child birth and post partum
period
Other danger signs during pregnancy, labor and child birth and post partum
period
Knowledge of key danger signs during pregnancy, labor and child birth and post
partum period
Scoring of knowledge of key danger signs
7
Knowledge and score of essential ANC components
34
8
Frequency and timing of ANC checkups
35
9
Information expected to be provided to pregnant women and their families
36
10
Knowledge and score of birth preparedness information steps
37
11
Knowledge on advice to be given during post partum Home visits
39
12
Antenatal care service provision
40
13
Birth preparedness service provision
41
14
Emergency transport provision
43
15
Provision of funds in pregnancy
44
16
Provision of blood/blood donor
45
17
Reasons for feeling rewarded
46
18
Themes from the qualitative responses
47
19
Interaction of the ASHAs with ANM, MO and AWW
50
20
Factors associated with the knowledge scores of key danger signs
54
21
Factors associated with knowledge scores of essential components of
55
4
5
ANC
vi
30
31
33
22
ANM support as associated with ANC service provision
56
23
Work Related Characteristics as related to ANC service provision
57
24
Birth preparedness knowledge as related to birth preparedness service provision
58
25
Birth preparedness knowledge as related to blood/blood donor provision
58
LIST OF FIGURES
Conceptual Framework of How Birth Preparedness/Complication Readiness May Increase
the Use of Skilled Care
6
LIST OF APPENDICES
Appendix 1
Interview Schedule in English
Appendix 2
Annexure 1 JSY document
Appendix 3
Annexure 2-D Operational Guidelines on Maternal and Newborn Health
Appendix 4
Annexure 3: Format for individual plans- Birth preparedness
Appendix 5
Informed consent
vii
Abstract
Background
Awareness of danger signs of obstetric complications and having a birth preparedness plan is the
essential first step in providing an appropriate and timely referral to obstetric care. The objectives of
this study was to understand whether community health workers (CHWs) there are equipped with the
knowledge and skills essential to help pregnant women developing complications get an appropriate
health care; and if the support and supervision they get from higher authorities is adequate to carry
out their assigned tasks in a rural backward district of Karnataka.
Methods
A cross-sectional descriptive study was carried out during June -July 2011. A total of 225 CHWs
were selected randomly for the study. A structured pre-tested interview schedule was used to collect
quantitative data on socio-demographic and work related characteristics, knowledge about danger
signs of pregnancy, childbirth and post partum period and service provision .Qualitative data was
collected as a series of responses to open ended questions. The collected data was analyzed using
SPSS for Windows version 17. Chi-square test was used to determine associations between
categorical variables. Themes around qualitative responses supplemented the quantitative data.
Results
Data was obtained from 207CHWs, yielding a response rate of 92%. Proportion of ASHAs who knew
key danger signs were 2(1%) for labor and child birth, 10(4.8%) for postpartum period and 15(7.2%)
for pregnancy. Composite score out of 10 showed a poor score of 0-3 ini 14 (55.1%), 4-5 in
78(37.7%), 6-7 in 15(7.2%), with none scoring above 7. Score for BP/CR out of 8 showed a
maximum score of 8 in 3(1.4%), 4-7 in 147(71%) and 1-3 in 57(27.5%). However, knowledge of
antenatal care (ANC) components was good with >=90% in 104(50.2%) of ASHAs. Knowledge of
key danger signs was significantly positively associated with number of rounds of training, recent
training and negatively associated with having a child less than 5 years of age. ANC service provision
was significantly associated with the extent of support received from auxiliary nurse midwives
(ANMs) of the public health system. Birth preparedness service provision was significantly
associated with birth preparedness knowledge level, experience, number of rounds of training,
practical training and recent training. Lack of regular payment to the CHWs was a major deterrent to
their services
Conclusion
CHWs seem to be poorly equipped to identify obstetric complications and to equip mothers with a
birth preparedness plan, although these are among their core responsibilities. Number of rounds of
training, practical training and recent training that CHWs received have an effect on the knowledge
levels related to danger signals in pregnancy, delivery and postpartum and knowledge of birth
preparedness plan. Those with better knowledge are seen to be more likely to provide related
services. CHWs are in need of frequent training, with a focus on practical training to identify key
danger signs. CHWs have considerable potential but need sustained support from the health system to
be able to make a difference to maternal mortality and morbidity in this district.
viii
CHAPTER ONE - INTRODUCTION
1.1 Background of study
In 1987 the international public health community launched the Safe Motherhood Initiative
(SMI) to raise awareness about the scope and consequences of poor maternal health, and to
mobilize action to address high rates of death and disability from the complications of pregnancy
and childbirth. The tenth anniversary conference held in Colombo, Sri Lanka, in 1997, concluded
that a skilled attendant to assist childbirth is the single most critical intervention to reduce
maternal mortality. In the year 2000, 189 countries signed the UN Millennium Declaration which
translated into the eight Millennium Development Goals (MDGs). MDG goal five focuses on
maternal health. However, it is seen that the progress on achieving this target is poor, especially
for the low-income developing countries. Although, evidence exists on interventions that can
impact on maternal, newborn and child health and survival, the availability of trained health
workforce to realize these interventions in various population settings is a serious concern.1'5
While Community Health Workers (CHWs)1 may not replace the need for sophisticated and
quahty health care delivery through highly skilled health care workers; they certainly play an
important role in increasing access to health care and services, and thus, improving health
outcomes.
Witmer et al (1995) defined community health workers (CHWs) as community members who work almost
exclusively in community settings and who serve as connectors between health care consumers and providers to
promote health among groups that have traditionally lacked access to adequate care.
Greater than 20 percent of maternal deaths globally occur in India.6 India faces several
challenges in meeting the needs of pregnant women, particularly for complications of pregnancy
and obstetric emergencies. Pregnancy related services are underused as pregnancy is regarded as
being a ‘natural’ phenomenon. Practices undermining the important of increased diet during
pregnancy and breast feeding practices are rampant.7 Anemia is the second largest cause of
maternal deaths (19 percent) and more than 50 percent of women are anemic with 17 percent
moderately or severely.8 This could be prevented if timely care and information and intervention
reaches to the population in need.6 Statistics available during 2006, suggests that over 60% of all
deliveries are still conducted at home, without a skilled birth attendant,9 63.6% report pregnancy
related complication, during childbirth it is 37% and 44.4% during the postnatal period.8 Studies
conducted in Andhra Pradesh, Maharashtra, and Rajasthan during 1998- 2000 show that 52%,
47%, 42% of maternal deaths, respectively, happen on the way to a hospital or at home.1012
There are other interrelated socio- cultural factors such as traditional beliefs, local healers who
are accessed first for any health conditions, which delay care-seeking and contribute to these
deaths in rural settings. Thus, CHWs in the Indian setting could promote behavior change for
care seeking, and strengthen household to hospital care continuum.
In India, the Accredited Social Health Activist program under the National Rural Health Mission
(NRHM) is seen to be following the long tradition of Indian Community Health Workers
(CHWs). The concept of community health workers dates back to the pre independence era and
the freedom struggle in India when in the 1940s the National Health (Sokhey) Sub-Committee of
the National Planning Committee of the Indian National Congress recommended a “community
health worker” for every 1,000 village population.13 Later, in 1977 the Village Health Guide
2
scheme was launched under the Rural Health Scheme 1977) by the Government of India,. The
village health guides were mostly women who were imparted training on basic preventive and
curative aspects of health, required to serve the village they resided and given a small incentive
for their work. They were also to play a role in fostering community participation in various
health activities in the villages they served.
The Accredited Social health Activist (ASHA) program is a key component of the National
Rural Health Mission (NRHM) launched in 2005.The term ASHA, in Hindi means “hope” The
ASHA is a woman primarily selected by the community, who resides in the community, is
trained, deployed and supported to function in her own village. Nearly 820,000 women have
been selected, trained and deployed as ASHA since 2005, and in terms of scale and coverage
there are few precedents to the ASHA programme anywhere in the world.14
The Janani Suraksha Yojana(JSY) a programme under NRHM to promote institutional
deliveries among women below poverty line (BPL) relies on the ASHA as a key functionary to
act as a link between pregnant women and accredited health facility. She has a role in counseling
women on issues such as birth preparedness and importance of safe delivery, arranging escort
services to accompany pregnant women, mobilizing funds, arranging transport and blood donor
to ensure better outcomes of pregnancy and child birth.15 ASHA program aims to provide the
women especially in the rural areas, with services which make maternity care accessible.
3
1.2 Problem Statement - Placing Karnataka and Koppal in the context of this study
The state of Karnataka has a population of 62 million.16 Although it is part of the more developed
southern part of India, its social and health indicators are only just above the national average,
and it trails behind its more advanced southern neighbors, Kerala and Tamil Nadu.17,18,20
Koppal, carved out of Raichur district in 1997, is a dry district with four talukas (sub-districts)
and is the most deprived district in Karnataka. The Karnataka Human Development Report ranks
Koppal at the bottom of all districts.20 In this district pregnant women’s experiences represent a
more complicated reality.21 The picture is very grim in addressing the three delays: in
recognizing complications and seeking care, in reaching appropriate health facilities and delays
in receiving appropriate care once having been admitted to the health facilities.22 It is in this
context that my research is placed to assess the role played by ASHAs at individual, family and
community level which seeks to minimize the first two delays thus enabling better outcomes of
pregnancy and childbirth.
1.3 Research Objectives
General objective
Contribute to the understanding of “safe motherhood” as perceived by the ASHAs.
Specific objectives
i.
To document the current levels of knowledge on components of antenatal care, danger
signs of pregnancy, delivery and post partum and to examine the factors associated with
4
current levels of knowledge.
ii.
To document the extent to which ASHAs provide services related to antenatal care,
delivery and postpartum period and to examine the factors associated with the extent of
service provision.
iii.
To understand the provision of emergency transport, funds, blood donor and associated
factors in complicated pregnancies.
iv.
To understand the nature of barriers and factors determining practice /non practice as
perceived by ASHAs on practicing birth preparedness and complication readiness.
1.4 Rationale of the Study
i.
There are very few robust assessments of the effect of birth preparedness and
complication readiness packages implemented via CHWs.
ii.
There are limited number of comprehensive studies in India, which measures the
knowledge competencies and performance of CHWs on maternal health outcomes.
iii.
CHWs based maternal health programmes of the past did not work, because CHWs did
not work within an “enabling environment” i.e.; where health care providers at primary,
secondary and tertiary levels function as a team, in which drugs and equipment are
available and effective supervision and systems of referral, are in place. This study of
mine attempts to explore the “enabling environment” in which the ASHAs work.
iv.
Training received by CHWs does not guarantee its application. Lack of knowledge on
basic issues, signals program managers with a clear message regarding the need for
additional or appropriate training.
5
1.5 Conceptual Framework
The conceptual framework below, developed by the JHIPEGO, is a usefill tool to visualize the
levels at and the pathways through which the ASHA can be expected to influence maternal
outcomes. ASHAs are expected to affect individual, family and community levels of Birth
preparedness and complication readiness by the way of providing awareness of danger signs,
informing women and their families on skilled providers, and other community resources such as
transport, blood donor and mobilizes community and aims at minimizing the first two delays of
care seeking, in order to ensure better and healthy outcomes of pregnancy and child birth.
Conceptual Framework of How BP/CR May Increase the Use of Skilled Care
Levels of
BP/CR
Possible pathways through which
BP/CR may reduce delays
Delays reduced
at each phase
Promotes skilled care for all births and
encourages decision-making before the
beginning of labor (and thus the onset of any
potential complications during childbirth).
Phase I:
Deciding to
seek care
Raises awareness of danger signs, thereby
improving problem recognition and reducing the
delay in deciding to seek care.
Individual
Family
Community
Provides information on appropriate sources of
care (providers, facilities), making the care
seeking process more efficient.
Phase II:
Identifying and
reaching
medical facility
-►
Encourages households and communities to set
aside money for transport and service fees,
avoiding delays in reaching care caused by the
search for funds.
Provider
Facility
Policymaker
Outcome
Improves staffing, provider skills, and enabling
environment and policies, which may reduce the
delay in receiving needed adequate and
appropriate treatment within a medical facility.
Improved quality may encourage people to decide
to seek care.
Improved availability may reduce the distance and
delay to reaching care.
//
Source: JHPIEGO/Matemal and Neonatal health Program
6
Phase III:
Receiving
adequate and
appropriate
treatment
*
Increased use
and
effectiveness of
skilled
attendance at
birth and other
key maternal and
newborn
services
1.6 Organization of thesis report
Chapter one of this report covers the background information, statement of the problem.
rationale for the study, research questions, objectives and conceptual framework. Chapter two
covers the review of the related literature. Chapter three is about methodology, which includes
the study design, data collection techniques and tools, sampling, ethical consideration. Chapter
four is the result. Chapter five discusses the results, refuting or confirming with the existing
literature. It also discusses the strengths and limitations of the study. This chapter also provides
policy implications, recommendations and conclusion. The recommendations will also be given
to the stakeholders. The list of references follows these chapters.
7
CHAPTER TWO - LITERATURE REVIEW
2.1 Introduction
The overall aim of my literature review was to identify CHWs programs with an impact on
Millennium Development Goal 5 - Maternal health including contributing to birth
preparedness and complication readiness. A comprehensive search was performed in various
data sources such as, Pub Med, Google and Google Scholar, reports and documents of
international agencies, government of India and Karnataka government, and pertinent books
and thesis.
The types of CHWs involved in the interventions studied, related to maternal health are the
♦♦♦ Community health workers (CHWs)
♦♦♦ Community mobilizers (CMs)
❖ Traditional birth attendants (TBAs).
2.2 Defining Birth Preparedness and Complication Readiness
“Birth Preparedness and Complication Readiness” is a strategy which promotes timely
use of skilled maternal and neonatal care especially during child birth, based on theory that
preparing for child birth and being ready for any complication reduces delays in obtaining
this care.23
Birth preparedness and complication readiness (BP/CR) is a common strategy employed by
numerous groups implementing safe motherhood programs, although the definitions vary.
Some of the standard elements of birth preparedness are knowledge of the danger signs.
8
choosing a birth location and provider, knowing the location of the nearest skilled provider,
obtaining basic safe birth supplies, and identifying someone to accompany the woman. It also
includes arranging for transportation, money, and a blood donor. The emphasis is on the
“demand side” that is, the individual, family and community, or the users of healthcare
services.
The Maternal and Neonatal Health (MNH) Program has expanded the concept of BP/CR to
address also the “supply side” of the equation, that is, the provider, the facility and the
policymaker. Inclusion of these additional levels indicates that factors causing delays in
seeking care for obstetric emergencies arise from many different sources, and therefore
require action from actors across multiple levels of society.
2.3 Evidence of CHWs in Birth Preparedness and Complication Readiness
2.3.1 Global Scenario
To help achieve the MDG-5, and to reach a wide range of populations who traditionally
lacked adequate access to care, many countries in Africa and Asia have invested in the cadres
ofCHWs.
Various countries have used alternative titles for CHWs,28 e.g. : Bangladesh (Shastho
shebika) India (Anganwadi worker, Basic health worker, village health guide, ASHA) Ghana
(community or village health workers) Pakistan (Lady Health worker), Ethiopia (Community
health agent) but the roles they played remains almost the same anywhere in the world. They
were especially found to be relevant in the rural settings.27,24,29’30
In Pakistan and Indonesia majority of CHWs were volunteers , and a few of them received
meager salaries 5,24 and in one study done in rural Malaysia transport cost was given.25
9
Salaried TBAs did not increase utilization of maternal services5 while it did have an impact
when case based remuneration was given in a study done at Indonesia.24
CHWs in different countries play a wide range of roles, from health education, community
mobilization and increasing utilization of services to referrals and actual service provision.
Thus, for many developing countries following Primary Health Care approach, CHWs helped
reaching populations in the remote and inaccessible parts of the world.34
In Pakistan, the Lady Health Worker mustered community participation and helped in the
creation of awareness and bringing about changes in attitude regarding basic issues of health
and family planning by establishing a comprehensive grass roots level effective system for
provision of primary health care to all its citizens.31
In Bangladesh29 where nearly 70% of the population resides in the rural areas community
based skilled birth attendant program addressed the grass root level needs of the pregnant
women in their community by the way of counseling and preparing for birth. They have had
the role of informing and motivating individuals and families on antenatal, postnatal care,
immunization and family Planning.,32’24,29135-41 Special counseling skills were imparted, to
help them encourage people to avail health services, and more so in the low income
communities.35 41,42 CHWs motivated women, their households and neighbors on pregnancy
care and need for skilled attendance,38 In Rural West-Java, Indonesia CHWs taught danger
signs.24 In China also evidence exists that CHWs gave health education and planned for
obstetric emergencies.43
10
In Guatemala30, training TBAs may have had a positive effect on the rate, detection, and
referral of postpartum complications in the rural underserved areas. But here the evidence
was less convincing on the overall rates of utilization of obstetric services. In Indonesia24 the
trained birth attendants in the rural areas enhanced complication referrals, taught mothers for
danger signs and improved the accessibility to skilled providers especially in the rural areas.
They had the role of recognizing and referring Emergency obstetric complications (EmOC)
32,24,30,36 40,44-4?
ap the chws driven interventional studies showed a significant
impact on maternal, prenatal and post partum service utilization indicators.
They were practically trained to immunize pregnant women with tetanus toxoid in a few
interventions.24,36,40 CHWs recognized and managed anemia 36 with iron and folate
supplements. Chemoprophylaxis for malaria 40,54 and curative treatment for parasitic
infections was also provided by CHWs.40 In Matlab, Bangladesh CHWs provided safe
delivery kit, iron and folate, family planning services.32,36 and managed childbirths.36 In
Rural West-Java, Indonesia CHWs distributed home based maternal and neonatal action
record.24 In China they provided prenatal services at grass root levels 43 In Nepal CHWs
managed of postpartum hemorrhage with Misoprostol provided Iron-folate to women, TT
doses and postnatal home visits.12 They also conducted normal deliveries.55,56 In Hangu,
Pakistan also similar interventions were done , but the results are less convincing for
complications detection, its referral and utilization of essential obstetric services.30
11
2.3.2 Indian Scenario
There are very few assessments of CHWs as outreach workers effecting birth preparedness
and complication readiness.
A family focused program field tested in one state of India and in three zones of Ethiopia
worked through CHWs. One major component was the use of pictorial cards for birth
preparedness, referral decision making, health care seeking and family planning. Recognition
of complications and first aid care in case of complications during and after pregnancy was
stressed upon. At the end of 3 years evaluation of services in India showed good progress
from the base line statistics. Over 76% prepared for birth and almost 76.2% adopted
breastfeeding within the first hour of birth from the base line of 1.7%. In Ethiopia too the
program built first steps towards responsive obstetric care. In Rewa district of MP,
knowledge and practices regarding birth preparedness of pregnant women and their family
members was done. The results suggested knowledge of danger signs (18.6%),
transportation services (18.6%), 1st trimester registration (24.1%) and population saved
money (44.2%).48In Indore,skilled attendance during delivery was three times higher in well
prepared mothers compared to less-prepared mothers.49
However, a few studies talk about one or a few components of BP/CR in various states in
India. In Mumbai and Orissa CHWs assisted women’s groups every month to consider the
causes and underlying problems leading to maternal and newborn deaths and develop
practical strategies.50,51 In Uttar Pradesh, CHWS helped behavior change and counseled
women on BP/CR but the emphasis were on new bom care.48 Pregnant mothers in Warda
Maharastra, were counseled on routine essential care during pregnancy but emphasis was on
new bom danger signs.52
12
A recent report (2011) is been released by the NHSRC 14 on the ASHA evaluation in the
eight states, (Andhra Pradesh, Assam, Bihar, Jharkhand, Kerala, Orissa, Rajasthan and West
Bengal). These states were chosen purposively to capture divergent contexts and
mechanisms.
Though a comprehensive evaluation of ASHA programme is been provided by the NHSRC,
the report does not provide an exhaustive account of ASHAs performance and skills with
respect to all aspects of Birth Preparedness and Complication Readiness. The focus appears
to be on providing information on JSY benefits. Counseling or educational inputs were
provided by the ASHAs during the home visits. In states like Assam, about 71% of women
were counseled on IFA tablets, and 70% on institutional delivery, with 67% having one
medical checkup. However, only 46% of beneficiaries reported having been counseled on
initiation of breast-feeding, 27% reported received any post partum care advice, and only
13.4% said they had received any advice on nutrition. On cautions for a home delivery only
5.3% received any tips on the basics of clean delivery. Advice on post natal care is also
neglected in most of these states. On most other parameters ASHAs do seem to be providing
active counseling
Over 90% of the ASHAs are seen to been functional in promoting institutional deliveries.
This also happens to be the most supervised elements in the programme. . Though ASHAs
are not trained to play a role of a birth companion the escort functionality of the ASHAs were
seen to be very relevant in the high focus districts. In a report of Madhya Pradesh CHWs
helped in creating the demand for services, helped increase of the ANC, PNC and prepare a
micro plan for pregnancy.53
13
Counseling on the basic cleanliness of home delivery is the lowest across states. It is not a
major concern in Kerala and AP where almost all respondents have had an institution
delivery, but it is a problem in the substantial number of home deliveries that have taken
place in the other states- even though they were users of ASHA services. Kerala had a good
schedule of meetings and the ANM (called JPHN) was much more available for playing this
role- as her work had either shifted up to the PHC or been shifted down to the ASHAmaking her a supervisor of an ASHA with little work outputs of her own.
The knowledge competencies, community ownership, and the supervision of CHWs are the
characteristics which are insufficiently described and analyzed in these available literatures
with respect to Birth preparedness and Complication Readiness. The literature examining the
knowledge of CHWs with respect to key danger signs during pregnancy, labor and post
partum period and the course of action subsequently taken were seldom found. These
characteristics would have helped me in understanding the importance of these factors on
CHWs performance on maternal health outcomes in community setting. The present study
aims to make a small contribution to the body of knowledge in this little explored area.
14
CHAPTER THREE - METHODOLOGY
3.1 Study design: Cross-sectional descriptive study.
3.2 Study setting: Koppal District in Karnataka
Target population
ASHA- Accredited social health activist
Source population
ASHA- Accredited social health activist in Karnataka as per NRHM norms (Koppal District)
There are 888 ASHAs currently working in the Koppal district.
Study subjects
225 of 888 ASHAs randomly selected in the district of Koppal.
3.3 Sampling and Sample techniques
3.3.1 Sample Size:
Based on a study at Madhya Pradesh,51 assuming 46% of the ASHAs have 60-70% knowledge level
related to birth preparedness and complication readiness and to get 95% Confidence Interval + 6%
using Statcalc the sample size was 204 and adjusting for non response rate of 10% it was found to
be 225.
3.3.2 Sanyling Technique:
Multistage Random sampling
15
3.3.3 Sample Selection Procedure:
There are a total of 39 PHCs in the four talukas of Koppal district. The talukas are Koppal, Yalburga,
Kustagi and Gangavati. I have randomly selected 2 of the 4 talukas, by the lottery method. These talukas
together have a total of 18 PHCs. All the 18 PHCs were included in my study. The sample of 225
ASHAs was randomly selected from these 18 PHCs using probability proportional to size sampling
method. Under probability proportional to size sampling, the sample of ASHAs were chosen as a
proportion to the total size of the population of ASHAs in the respective PHCs.
3.3.4 Selection Criteria :
Inclusion criteriai.
ASHAs working for at least 6 months
ii.
Willing to participate in the study
iii.
Willing to provide a written informed consent
Exclusion criteria^
i.
ASHAs working for less than 6 months
ii.
Not willing to participate in the study
iii.
Not willing to provide a written informed consent
16
3.4 Study variables
3.4.1 Operational Definition of Independent Variables:
Background Variables
1. Age-:
The age of ASHA in completed years was asked. A categorical variable was created as a measure
for ASHAs age. The categories were 20-24 years, 25-29 years, 30-34 years, 35-39 years and
>=40 years.
2. Marital Status-:
This variable defined as a woman whose traditional marriage has been performed. A variable was
created by categorizing into never married, married, widowed, divorced and separated.
3. Education-:
The last level of education completed by the ASHAs was asked. A variable for the ASHAs
education was created by categorizing into <8standard, 8-9th standard, completed 10th standard.
11 -12th standard, post 12th diploma/certificate course and graduation
4. Having Children less than five years of age -:
A dichotomous variable was created for this, if ASHA said that she had a child less than five
years of age then, she was assigned a score of “1” if she replied in negative then a score of “0”
was assigned.
17
Work related Variables
1.
Experience:The categorical variable was created based on the response to the question “since when are
you working as ASHA?”The categories were 6-12 months, 13-24months, 25-36 months
and >36 months.
2.
Rounds of Training:The categorical variable was created depending on the number of rounds of training
received. The categories were 1 round, 2 rounds, 3-4 rounds and >4 rounds.
3.
Practical training:A dichotomous variable was created for this, if ASHA said yes to have received practical
training, then a score of “1” was assigned or otherwise ‘0” was assigned.
4.
Training in the last 3 months :A dichotomous variable was created for this if ASHA said yes to have received training in
the last 3 months preceding the survey, then a score of “1” was assigned or otherwise ‘0”
was assigned.
5.
Time taken to reach the nearest PHC:A categorical variable was created depending on the time taken to reach the nearest PHC.
The categories were <30 minutes, 30-60 minutes, 61-120 minutes and >120 minutes.
3.4.2 Operational Definition for Dependent Variables
The operational definition for dependent variables were derived from the expected role of
ASHAs vis-a-vis pregnancy related care, birth preparedness and complication readiness as per
18
NRHM Gol guidelines Annexure 1 JSY document, Annexure 2-D Operational Guidelines on
Maternal and Newborn Health, Annexure 3: Format for individual plans- Birth preparedness.
1. Proportion of ASHAs with knowledge of essential components in ANC:Numerator: Number(#) of ASHAs who spontaneously mention early registration, regular weight
check, blood test for anemia, measurement of blood pressure, IFA tablets for 3 months, nutrition
education^ doses of tetanus toxoid, hygiene education, birth preparedness and complication
readiness .Denominator: # of ASHAs interviewed
2. Proportion of ASHAs with knowledge of key danger signs during pregnancy-:
Numerator: # of ASHAs who spontaneously mention the three key danger signs during pregnancy
(severe vaginal bleeding, swollen hands/face, and blurred vision) Denominator: # of ASHAs
interviewed
3. Proportion of ASHAs with knowledge of key danger signs during delivery-:
Numerator: # of ASHAs who spontaneously mention the four key danger signs during
labor/childbirth (severe vaginal bleeding, prolonged labor (>12 hours), convulsions, and retained
placenta) and include severe bleeding Denominator: # of ASHAs interviewed
4. Proportion of ASHAs with knowledge of key danger signs during postpartum period-:
Numerator: # of ASHAs who spontaneously mention the three key danger signs during the
postpartum period (severe vaginal bleeding, foul smelling vaginal discharge, and high fever)
Denominator: # of ASHAs interviewed
19
5. Proportion of ASHAs who provide essential antenatal care services-:
Numerator: # of ASHAs who spontaneously mentioned actual provision services such as helping in
registration for JSY scheme/ for ANC services, calculating date of delivery,
visits, helping with at least 3 ANC checkups, facilitating TT injections
providing home
providing Iron/Folate
tablets, invite them to attend health day, get nutrition supplements from Aanganwadi center in the last
1 month preceding the survey to pregnant woman. Denominator: # of ASHAs interviewed
6. Proportion of ASHAs who provide birth preparedness components:-
Numerator: # of ASHAs who spontaneously mentioned actual provision services such as counsel for
institutional delivery, explain cash assistance benefits for institutional delivery, explain transport
assistance benefits for institutional delivery, identify a functional Government health centre or an
accredited private health facility, identify institution for referral /delivery and identify blood donor in
the last 1 month preceding the survey to pregnant woman. Denominator: # of ASHAs interviewed
7. Proportion of ASHAs who arrange for transport:-
Numerator: # of ASHAs who spontaneously mentioned actual provision of transport services such as
108/auto/private vehicle, 108 only, hospital ambulance, auto, families arranged and two wheeler of
the families for pregnant woman. Denominator: # of ASHAs interviewed.
8. Proportion of ASHAs who helped provision of funds:Numerator: # of ASHAs who spontaneously mentioned actual provision of funds by the way of
counseling the families and pregnant woman, from VHSC funds or a combination, VHSC funds
alone or no provision. Denominator: # of ASHAs.
20
9. Proportion of ASHAs who helped in the provision of blood/blood donor:Numerator: # of ASHAs who spontaneously mentioned actual provision of blood/blood donor as
doctor at the PHC/CHC, both ASHA and the doctor, only ASHA, NGO, combination of doctor,
ASHA and NGO and no provision. Denominator: # of ASHAs.
10. Support received by the ASHAs from ANM,MO,AWW were examined from the quahtative
information provided, which helped to examine the extent to which the support contributed to
knowledge and service provision .
1.
Optimal support - If frequency >4 times per week and duration >2 hours or 1 -2
hours per interaction
2. Moderate support - If frequency 2-4 times per week and duration of <1 hour or 1 2 hours or > 2 hours per interaction and frequency >4 times per week and duration
of <1 hour per interaction.
3. Suboptimal support - If frequency > 2 times per week and duration < 1 hours or 1 2 hours or > 2 hours per interaction
3.5 Data collection techniques and tools
3.5.1 Development of the Interview Schedule
The semi-structured interview schedule was predominately adapted from the “Monitoring
birth preparedness and complication readiness- tools and indicators for maternal and
newborn health” The Maternal and Neonatal Health (MNH) Program of the JHPIEGO.
The schedule was modified according to the training curriculum of the ASHAs and
21
operational guidelines on maternal and newborn health of the NRHM. This was carried
out by me in consultation with an expert in field of Reproductive Health Research. It was
developed in English which was translated into Kannada by an independent translator and
then back translated into English by a third independent translator. This was done to
improve the validity and reliability of my interview schedule.
The headings of the main sections of the 12 - page interview
schedule are as follows1.
2.
3.
4.
5.
6.
Background information of ASHA
Pregnancy related Knowledge
Labor and childbirth related knowledge
Post partum care Knowledge
Antenatal care service provision
Support Mechanisms and barriers
3.5.2 Pre-testing
Pre-testing of the interview schedule was done in approximately 5% of the estimated sample
size in a rural setting of another district in Karnataka and relevant modifications were carried
out.
3.5.3 Data Collection Procedure:
Data collection was carried out over a six -week period from June to July 2011.1 and my
research assistant visited each PHC over a period of two days. On the first day, we
introduced ourselves and explained the study objectives.
22
I also collected the phone numbers of the ASHAs from the PHC. My local research assistant
helped to contact the ASHAs, convey the study aims, took initial consent over phone, and
fixed a place convenient for them to be interviewed.
The second day was used to collect data. To avoid contamination of my data I collected the
data from the ASHAs working under the same PHC and Sub center within a span of two days
so as to avoid them discussing the type of questions asked. It was an interviewer
administered method, where the research assistant read out the content of the interview guide
and recorded as appropriate the responses of the respondent. The whole process of asking the
knowledge based questions was unprompted. Spontaneous responses were expected of
ASHAs. Spontaneous knowledge here refers to the ASHAs naming a sign or response
without being asked about that sign by name.
It was very important not to change the meaning or interpretation of the danger sign when
been translated to English from the local terminology. The research assistant helped me
understand the danger sign as it was mentioned in the local dialect. I took utmost care to
translate the names of danger signs in English as per the medical terminology reconfirming
with other Medical officers when required.
To achieve the calculated sample size a total of 225 ASHAs from 18 PHC were contacted
.There were 207 ASHAs who were found eligible according to my inclusion criteria and
provided written consent. The non- response rate was 8%, which was lesser than the expected
non-response rate of 10%.
23
3.6 Data analysis
The collected data were coded, entered, and cleaned, and analyzed by SPSS for windows
version 17. The principal investigator coded all questionnaires before their administration.
Completed questionnaires were sorted out, collated and cleaned. Cross validation and
consistency checks were done. The results were presented in tables showing proportions of
the distribution of the characteristics. Cross tabulations were used to compare the
characteristics of chi square and p-value.
3.7 Ethical considerations
Ethical considerations involved ethical review, informed consent, confidentiality, as well as
risks and benefits. Ethical clearance was obtained from Institute Ethics Committee (IEC);
SCTIMST. Written informed consent was obtained from individuals found to be eligible
and willing to participate in the study. Efforts were made to identify places for interviews
which ensured privacy, participant convenience and no interruption. No information about
ASHA’s scores on knowledge questionnaires was shared with their supervisor or colleagues.
Anonymity was maintained throughout this survey from the data collection up to the write
up of the dissertation. Data was securely handled by using a password on the computer
which stored the data that has been entered as a soft copy as soon as it was collected. The
computer which stored the data was handled by the researcher only. After all the data had
been entered and stored in the computer, the hard copy of the questionnaires was stored in a
locker and locked for safe keeping.
24
CHAPTER FOUR - RESULTS
4.1 Sample Characteristics
4.1.1 Socio-demographic characteristics
The median age of the ASHAs interviewed is 30 years; the range is 20- 57 years. Almost all
were married 201(97.1 %) Since there was an underlying assumption that ASHAs having
children less than five years of age may not be able to spare adequate time to their work and
responsibilities, the same included as a question. Only 39(18.8%) of the ASHAs had children
below five years of age..
Though the Government of India guidelines mention ASHA s to preferably have at least 8th
standard education to work, it allows for a lesser qualified women to take up work as ASHAs
in case women with this minimum education level are not available. My study sample had
79(38.2%) of the ASHAs with less than the specified 8 th standard education. Of these there
were around 16(7.2%) ASHAs had less than 4th standard education level.
Table 1: Socio-demographic characteristics of the sample population (N=207)
Variable
n (%)
Age
20-24
23(11.1)
25-29
73(35.3)
30-34
72(34.8)
35-39
30(14.5)
>=40
9(4.3)
Marital Status
Never Married
6 (2.9)
Married
201 (97.1)
25
Variable
n(%)
Children less than 5 years
Yes
39(18.8)
No
168(81.2)
Education
<8th standard
79(38.2)
8-9th standard
38(18.4)
completed 10th standard
67 (32.4)
11-12th standard
19(9.2)
post 12th dip loma/certificate
2(1)
course
graduation
2(1)
Source: Primary survey, 2011
4.1.2 Work related characteristics
A vast majority 163 (78.7) of the ASHAs were working since two to three years.. Nearly
two-thirds of the ASHAs, 136(65.7%) had received one round of training which is the 23
days of introductory training provided to all the ASHAs in the district, 69(33.3%) of them
received 3-4 rounds of training and an insignificant proportion had received two rounds of
training 2(1%). Induction training is to be completed in 23 days spread over a period of 12
months. The first round is of seven days, to be followed by another four rounds of training,
each lasting for four days to complete induction training. After the induction training,
periodic re-training is to be held for about two days, once in every alternate month at
appropriate level for all ASHAs. During this training, interactive sessions will be held to
help refresh and upgrade their knowledge and skills, trouble shoot problems they are facing,
monitor their work and also for keeping up motivation and interest.
26
Competencies to be developed in ASHAs after 20 days of training include general
competencies, maternal care and home based newborn care as specified in annexe 2-D
operational guidelines on maternal and newborn health.
Majorityl72 (83.1%) of the ASHAs have not received any form of practical training. Only
35(16.9%) of the ASHAs reported undergoing some kind of practical training, 22 at the
Taluka hospital and 13 at the district training centre. The content of practical training was
predominantly home based newborn care, with little or no emphasis on issues during
pregnancy and child birth.
Sixty — seven (32.4%) of the ASHAs said that that they received some form of training
within the last three months preceding the survey.
Distance from the ASHA’s home to the nearest PHC was included as a variable because this
factor would affect the extent of supervision she may get, her interaction and involvement
with the PHC activities and subsequently her service provision. A little less than a third of
the ASHAs (64) could reach the nearest PHC within 30 minutes, 58(28%) and 54(26.1%)
lived within a distance of between 30 minutes- 60minutes and,61 minutes- 120 minutes
respectively. A small number - 31(15%) - of the ASHAs reported took around 2 hours to
reach the nearest PHC. They also reported having to spend money for the bus and private
vehicles which were not reimbursed and so most of them came walking.
27
Table 2: Work Related Characteristics of the sample population (N-207)
n(%)
Variable
Experience
6-12months
4(1-9)
13-24months
9 (4.3)
25-36months
163 (78.7)
>36months
31 (15)
Training Received
1 round
136 (65.7)
2 rounds
2(1)
3-4 rounds
69 (33.3)
Practical Training
yes
35 (16.9)
no
172 (83.1)
Venue of Practical Training
Taluka hospital
27(77.1)
Training centre
8(22.9)
Training within last 3 months
yes
67(32.4)
no
140(67.6)
Time to reach nearest PHC
<30 minutes
64(30.9)
30-60 minutes
58(28.0)
61- 120 minutes
54(26.1)
>120 minutes
31(15.0)
Source: Primary survey, 2011
28
4.2 Knowledge levels
4.2.1 Knowledge of the danger signs
Knowledge of the danger signs of obstetric complications is the essential first step in the
appropriate and timely referral to essential obstetric care which is of critical importance
in decreasing maternal mortality.
The ASHAs were asked to mention what they knew to be key danger signs during
pregnancy, labor and child birth and immediate post postpartum (first 2 days) period.
Their responses were compared against a list of key danger signs that may be considered
as minimum essential knowledge for ASHAs.
The danger signs considered were derived from the ASHAs training curriculum, were
selected as key because they are common, easy to recognize, and associated with a
potentially severe problem. These were adapted from monitoring Birth preparedness and
complication readiness tools and indicators for maternal and newborn health.
.Recognition of the problem, its perceived causes and feared outcome will generally
determine how a problem is managed by ASHAs. For this reason the knowledge of
danger signs was followed by whether they perceived it to be fatal or not (all key danger
signs are associated with a high risk of maternal death).
29
Table 3: Key danger signs during pregnancy, labor and child birth and post partum
period
Key danger signs during
Pregnancy
1. Severe vaginal bleeding
2. Swollen hands/face
3. Blurred vision
Labor and child birth
Post partum period
1. Severe vaginal bleeding
2. Prolonged labor (> 12
hours)
3. Convulsions
4. Retained placenta
1. Severe vaginal
bleeding
2. Foul-smelling
vaginal discharge
3. High fever
Source: JHPIEGO/Matemal and Neonatal Health Program, Knowledge ofkey dangtrer
signs, Indicators 1.1 to 1.3.
Apart from the key danger signs identified by us, the following correct danger signs
were also noted when spontaneously mentioned by respondents
Table 4: Other danger signs during pregnancy, labor and child birth and post
partum period
Other Danger signs during
Pregnancy
•
•
•
•
•
•
•
•
•
convulsions
severe headache
high fever
loss of consciousness
difficulty breathing
severe weakness
severe abdominal pain
accelerated/ reduced
fetal movement
water breaks without
labor
Labor and child birth
•
•
•
severe headache
high fever
loss of
consciousness
Post partum period
•
•
•
•
•
•
•
severe headache
blurred vision
convulsions
swollen hands/face
loss of consciousness
difficulty breathing
severe weakness
Source: JHPIEGO/Matemal and Neonatal Health Program Sections.Knowledge
30
Table 5: Knowledge of key danger signs during pregnancy, labor and child birth and
post partum period
Knowledge levels N(207)
Pregnancy
N (%)
All Key danger signs +
Others_____________
All key Danger signs
Post partum
N (%)
15 (7.2)
Labor and child
birth
N (%)
0
0
2(1)
1(.5)
Not all key danger signs
152(73.5)
186(89.8)
188(90.9)
None of the key danger
signs_________________
Aware that the condition
could be fatal
N(207)________________
All Key danger signs +
Others
40(19.3)
19(9.2)
9(4.3)
Pregnancy
N (%)
Post partum
N (%)
13(6.3)
Labor and child
birth
N (%)
0
All key Danger signs
0
0
1(.5)
Not all key danger signs
142(68.6)
177(85.5)
169(81.2)
None of the key danger
52(25.1)
signs______________________
Source: Primary survey, 2011
30(14.5)
31(15)
9(4.3)
6(2.9%)
a. Knowledge of the danger signs during pregnancy
Only 15 (7.2%) ASHAs correctly identified all key danger signs considered by the study
plus a few other danger signs. Thirteen (6.3%) considered the stated danger signs to be
potentially life threatening and two ASHAs did not consider danger signals severe
enough to take action. None of the key danger signs were mentioned by 40(19.3%).
31
- sopHtA-soo*** A i>
Id
l-JH
^1/
)
b. Knowledge of the danger signs during labor and child birth
The knowledge of the respondents of key danger signs during labor and child birth was
very poor with only 2(1 %) of the ASHAs correctly identifying the key danger signs
considered in this study. Nineteen (9.2%) respondents had no idea on any of the key
danger signs. The fatality perception was equally bad with none of them considering the
key danger signs potentially fatal.
c. Knowledge of the danger signs during immediate post partum period
Around 9(4.3%) of the ASHAs mentioned all the key danger signs plus a few others,
only 6(2.9%) considered it potentially fatal. Though not all key danger signs were
mentioned by 188(90.9%) a vast majority of respondents mentioned excessive vaginal
bleeding as a key danger sign leaving out foul smelling vaginal discharge and high
fever. This suggests the post partum hemorrhage was a high priority danger sign for
most of the ASHAs as 169(81.2%) of them also considered it potentially fatal. 31(15%)
of the ASHAs considered none of the key danger signs fatal.
(L Scoring of Knowledge of key Danger signs
The number of key danger signs was three, four and three during pregnancy, labor and
child birth and post partum period respectively. A composite knowledge score of the
key danger signs was computed by summing up the responses obtained in all the three
scenarios for each respondent. The maximum score would be 10 and the minimum
would be zero.
32
Table 6: Scoring of knowledge of key danger signs (N=207)
Scoring of Key Danger signs
n(%)
Score 0-3 - Very poor
114(55.1)
Score 4-5 - Poor
78(37.7)
Score 6-7 - Average
15(7.2)
Score 8-10
None
Source: Primary survey, 2011
4.2.2 Knowledge related to antenatal care service delivery
According to the ASHAs training curriculum all women should receive four routine
antenatal (ANC) checkups. To detect problems associated with pregnancy and childbirth.
WHO recommends attending four ANC visits, with the first visit occurring during the first
trimester. National policies vary regarding the number of visits and in India though ideally
four ANC checkups are indicated at least 3 ANC checkups are considered mandatory.
Though ANC cannot prevent the major complications of childbirth; never the less it is
believed that certain ANC interventions can lead to early detection and timely intervention
reducing the number of poor maternal outcomes.
a. Components ofAntenatal care
A majority of the ASHAs correctly spontaneously mentioned most of the eight
components as specified by the training modules.2However only 72(34.8) reported
The components also include birth-preparedness and complication readiness, but these have not been
considered because they are discussed in detail subsequently.
33
hygiene education to be an essential component. Nutrition education as an essential
component was reported by only 138(66.7%) of the respondents.
The maximum score for correct knowledge of essential components of ANC, on a scale of
0-8, was eight and the minimum was two. About half (50.2%) of the ASHAs mentioned
seven or eight of the eight essential components as suggested by her training curriculum
Table 7: Knowledge and score of essential ANC components (N=207)
Antenatal care components
spontaneously mentioned
Components
N (%)
Regular weight check
150(72.5)
Essential
Components
N (%)
149(72)
Blood test for anemia
204(98.6)
204(98.6)
Urine test for protein and sugar
188(90.8)
184(88.9)
Measuring blood pressure
197(95.2)
196(94.7)
IFA for 3 months
199(96.1)
193(93.2)
Nutrition Education
141(68.1)
138(66.7)
2 Doses of Tetanus Toxoid
204(98.6)
205(99)
Hygiene Education
73(35.3)
72(34.8)
Scoring of Essential Components of ANC
N (%)
Score 2-6 - Average
103(49.8)
Score 7-8 -Good
104(50.2
Source: Primary survey, 2011
34
b. Frequency and Timing ofANC checkups
Frequency of the ANC checkups were reported correctly by 186(89.9%) of the
respondents. The vast majority 204(98.6%) of the ASHAs also accurately mentioned the
timing of the first ANC checkup as to be in the 1st trimester.
Table 8: Frequency and timing of ANC checkups
Frequency and Timing of
ANC checkups (N=207)
Correct responses n (%)
frequency of ANC checkups
186(89.9)
sTiming of 1st ANC checkup
204(98.6)
Source: Primary survey, 2011
# 3 and 4 ANC checkups considered as correct responses
$ 1 st trimester considered correct response
c. Information to be provided during home visits
Tabled & below presents the activities that were expected to be spontaneously mentioned
for the questions on information provided to pregnant women and her family during
home visits, and responses to these.
Surprisingly, the information regarding maternal complications being unpredictable but
treatable and discussing the signs and symptoms of complications during pregnancy and
delivery were two important information neglected by all the respondents. A meager
proportion of 28(13.5%) of ASHAs ever mentioned the fact that all pregnant women are
at risk of developing pregnancy related complications.
35
Table 9: Information Expected to be provided to pregnant women and their
families
d.
Information Expected to be Provided to pregnant women
Yes
No
and their families (N=207)
n(%)
n(%)
That all pregnant women are at risk of developing pregnancy
related complications
_______________
That maternal complications are unpredictable but are
treatable
28(13.5)
179(86.5)
0
207(100)
That completing all three ANC visits is important
144(69.6)
63(30.4)
Discussions on plans for delivery (e.g. intention of where to
deliver, who the pregnant woman wants to be present at her
delivery, contingency plans in the event of complications
Signs and symptoms of complications during pregnancy and
delivery___________________
Source: Primary survey, 2011
25(12.1)
182(87.9)
0
207(100)
Knowledge related to Birth preparedness plan
The three delays mentioned in my conceptual framework for Birth Preparedness and
complication readiness is common and predictable. In order to address these three
delays, ASHAs have the responsibility to inform the women and families to be prepared
in advance and ready for any rapid emergency action during pregnancy and delivery.
Table 10 below indicates the information spontaneously expected for the question on
things that a woman is expected to do, in order to be well prepared for birth and the
responses to these. These are adapted from the Birth Micro Plan3 of the ASHAs of her
training curriculum.
3 Annex 3: Format for individual plans- Birth preparedness) and Operational guidelines on
Maternal and Newborn Health of the NRHM
36
Table 10: Knowledge and score of Birth preparedness information steps
Birth Preparedness Steps Information to
Yes
No
be provided (N=207)
N (%)
N (%)
Identify health facility
174(84.1)
33(15.9)
Identify skilled provider
43(20.8)
164(79.2)
Identify mode of transport
157(75.8)
50(24.2)
Save money for delivery
173(83.6)
34(16.4)
Save money for transportation
86(41.5)
121(58.5)
Identify blood donor
7(3.4)
200(96.6)
Identify the person who will escort to skilled care
10(4.8)
197(95.2)
Prepare clean items for birth
171(82.6)
36(17.4)
Birth Preparedness Information Score
Excellent -Score 8
N (%)
3(1.4)
Good-Score 4-7
147(71)
Poor -Score 1-3
57(27.5)
Source: Primary survey, 2011
Although 174(84.1%) of the ASHAs mentioned identification of a health facility for
delivery, only 43(20.8%) of had mentioned identifying a skilled person to carry out the
delivery. About 75 per cent of the ASHAs mentioned the identification of some or the
other mode of transport as part of the birth-preparedness plan.
A vast majority of the ASHAs 173(83.6%) noted advising the women to save money
every month in a piggy bank to pay for delivery and transport expenses as part of
preparing for birth. However, only 7(3.4%) of the respondents knew that a blood donor
needed to be identified, a major omission in terms saving maternal lives.
37
Only 10(4.8%) of the respondents mentioned identifying an escort to accompany the women
for delivery.
An emergency response mechanism in any pregnancy is a combination of the above steps
and in the context of my study it is ASHAs responsibility to help her develop a birth
preparedness plan.
e. Scoringfor knowledge of Birth preparedness information
The score for the birth preparedness information (8 steps) was computed for each respondent
from the components mentioned above. The maximum score was 8 and the minimum was
1 .Only 3 (1.4%) of the respondents exactly did what was expected of them as per their
training curriculum. However, a vast majority (71%) scored 4-7, while about a quarter
27.5%) scored poor with 1-3 score.
4.2.3
Knowledge of post partum checkups and advice
Getting postpartum care soon after giving birth is crucial for the health o the woman. This
visit could be in response to a problem, or just for a routine checkup. The question I asked
was how many times should a mother have post partum checkup after birth. The answer
expected was three times: at 6 hours, 6 days, and 6 weeks postpartum and any time she has
danger signs.
Unfortunately none of the ASHAs could mention the correct frequency for post partum care.
Here, I also got answers like if the birth took place in a health facility and happened to be a
normal delivery, there was no need for post partum checkup. Also, some of the ASHAs
opined that the post partum care was for the newborn and not for the mother.
38
Table 11: Knowledge on advice to be given during Post partum Home visits
Advice to be given during Post
N (%)
partum Home visits
Rest for at least 6 weeks
0
Eat more food especially high
177(85.5)
protein foods
Exclusive breast feeding for 6
203(98.1)
months
Need for contraception
5(2.4)
Source: Primary survey, 2011
The post partum care training which is covered in ASHA module 2, suggests the above
mentioned four activities to be undertaken during post partum home visits. It is the
responsibility of ASHAs to counsel the woman and her family to rest for at least weeks
after childbirth and not to engage in heavy manual labor. None of the ASHAs reported
advice on rest for at least 6 weeks after delivery as a component of information to be
given during the postpartum visit. ASHAs also has the responsibility on discussing the
need for contraception; caution the woman the risk of unprotected sex, importance of
spacing the next birth for her own health and that of the baby and help her make a choice
of family planning. ASHAs did not seem to know that this was a part of home visits after
delivery. This is a major lacuna.
But majority of them mentioned advocating for exclusive breast feeding for 6 months
and essential advice to postpartum women.
39
4.3 Service Provision by the ASHAs
4.3.1 Antenatal Care Service Provision
There are various components of ANC provision that ASHAs are expected to deliver as
per her training curriculum. Two questions were asked: one on what she is expected to
provide, and another on what she actually provided. Knowledge of what is to be done is
of course a major factor that would influence whether the concerned service is provided.
In addition, the actual provision is subject to various factors such as level of supervision,
and other background variables and work related variables discussed in the sample
characteristics.
Table 12: Antenatal care Service provision
Antenatal care Service provision
spontaneously mentioned
Actual Provision in the last 1
month
N (%)
Helping in registration for JSY
scheme/ for ANC services
Calculating date of delivery
207(100)
Providing Home visits
202(97.6)
Helping with at least 3 ANC
checkups_________________
Facilitating TT injections
202(97.6)
Providing Iron/Folate tablets
88(42.5)
Invite pregnant women to attend
health day_____________________
Get nutrition supplements for
pregnant women from Aanganwadi
center________________________
138(66.7)
58(28)
205(99)
7(3.4)
Source: Primary survey, 2011
Calculation of expected date of delivery was very low 58(28%). Only 42.5% provided
40
iron and folate tablets. This was reportedly because these tablets were not available at
the facility. The women were advised to buy the medicines privately from the local
pharmacy.
Though her curriculum suggests that she help the pregnant lady get the nutrition
supplements from the Aanganwadi center, the ASHAs here were not providing the same
which needs further exploration.
4.3.2 Birth Preparedness Service Provision
Table 13: Birth Preparedness service provision
Birth Preparedness Service provision
Provision
Counsel for institutional
delivery
Explain cash assistance
benefits for institutional
delivery
Explain transport assistance
benefits for institutional
delivery
Identify a functional
Government health centre or
an accredited private health
facility for delivery
Identify Institution for referral
/delivery
Identify blood donor
Source: Primary survey, 2011
Actual
204(98.6)
203(98.1)
191(92.3)
185(89.4)
3(1.4)
1(.5)
Counseling for institutional delivery was provided by the vast majority (98.6%) ASHAs.
41
Almost all the ASHAs 203(98.1%) reportedly mentioned cash benefits assistance for
institutional delivery. Majority 191(92.3%) of the ASHAs explained transport assistance
benefits available.
We saw earlier that a very small proportion of ASHAs knew that identifying an
institution for referral and a blood donor were components of birth preparedness. This is
reflected in the finding that only 4.3 per cent of the respondents said that they identified
an institution for referral, almost no one 1(0.5%) actually did identify the blood donor.
4.3.3 Provision of Emergency transport. Funds and Blood
The “108 Emergency service” a free service delivered through state- of-art
emergency call response centers across various states in India is exclusively sought by
ASHAs in 58(28%) of the cases. This 108 ambulance service can be availed by people
by dialing a toll free 108 from landline or any cell service providers service in case of
any medical emergency. A combination of 108 services, auto, or other private vehicle
like taxis were used in case of emergencies according to 81 (39.1%) of the
respondents. It was said that in case 108 services replied that it would take longer,
they opted for either auto or taxi which was very expensive for the families to afford.
But overall the ASHAs were of opinion that the 108 services were good.
42
Table 14: Emergency Transport Provision
Emergency Transport Provision
(N=207)_____________________
108/Auto/private vehicle
108
Families arrange
Auto
Hospital Ambulance
Two wheeler of families
Source; Primary survey, 2011
N (%)
81(39.1)
58(28)
45(21.7)
20(9.7)
2(1)___
1(.5)
The time taken to arrange transport for perceived high risk was asked to find out the
extent of delay experienced once they decided to seek care This also was an indication
of how the health system and other community resources were prepared to help the
pregnant women in times which were critical. It was reported that around 100 (48.3%)
of the ASHAs took more than 30 minutes to arrange transport in times of emergency.
Only 26(12.6%) of the ASHAs took less than 15 minutes to arrange transport.
After arranging for transport to reach the health facility it took more than two hours for
normal deliveries in 11(5.3%) of the ASHAs responses. The pregnancies perceived to
be high risk in 19(9.2%) of the responses took less than 30 minutes and in 50(24.2)
responses took more than two hours in reaching the higher health facility. This clearly
suggests that in nearly one-fourth of the perceived high risk cases had delay of more
than two hours just to reach the facility, which was critical period for the health of both
mother and the child.
43
Table 15: Provision of Funds in pregnancy
Provision of Funds in pregnancy
(N=207)_____________________
Counsel women and family to save
N (%)
136(65.7)
money
Counsel women and family to save
57(27.5)
money + Arrange VHSC funds
VHSC funds alone
2(1)
No provision
12(5.8)
Source; Primary survey, 2011
As for provision of funds for seeking delivery care, although exclusive counseling to
save money for delivery was done by a vast majority of the ASHAs 136(65.7%), a little
more than a quarter of them arranged the funds from Village Health and Sanitation
Committee (VHSC) in addition to the counseling. VHSC reported to have helped with
an amount of Rupees two hundred towards transport expenses in the case of very poor
families. Unfortunately, there was no provision of funds by 12 (5.8%) of the ASHAs.
It was reported that even in the case of normal deliveries there was a cost of less than
two hundred rupees to reach the health facility in nearly three - fourth of the cases and
in nearly a quarter of the perceived high risk pregnancies it cost more than five hundred
rupees which is definitely unaffordable by the families living in poverty.
44
Table 16: Provision of blood/blood donor
Blood/ Blood donor Provision
N (%)
(N=207)
Doctor at PHC/CHC helps
112(54.1)
Both ASHA and doctor help
34(16.4)
Only ASHA
2(1)
NGO
1(5)
Doctor+ ASHA+NGO
13(6.3)
No provision
45(21.7)
Source: Primary survey, 2011
The ASHAs also reported that in more than half of the situations needing blood/blood
donor the doctor at the PHC/CHC was solely responsible was arranging blood.
Unfortunately, ASHA reported no provision of blood or didn’t know how to do it in
nearly a quarter of the cases.
4.4
Supportive factors and barriers
From the analysis of quahtative responses, four major themes emerged from the narratives
of 37 ASHAs practicing / non practicing Birth preparedness and complication Readiness.
There were factors operating at the individual, family, community and the health system
levels during instances of her service provision towards pregnant woman.
Z.
Individual level
It was reported by nearly 165(79.7%) of the respondents that they felt rewarded working as ASHA.
45
Table 17: Reasons for feeling rewarded(N=207)
Reasons for feeling rewarded
n(%)
Recognition in community
3(1-4)
Ability to make a difference in other
35(16.9)
women’s lives
Being able to help others
149(72)
Opportunity to learn new thing
21(10.1)
Appreciation from superior
6
Source: Primary Survey ,2011
Nearly a quarter of ASHAs who did not feel rewarded cited the lack of payment as a
major reason. Nearly three-fourth of the respondents said they felt rewarded as they were
of some help to the woman in their villages. Sadly, none of the respondents cited as been
appreciated by their superiors as the reason .This certainly would have an effect on their
motivation level and subsequently affect their service provision.
Individual narratives showed the high level of motivation on the part of many ASHAs.
“ When every pregnant lady I escort /help delivers a healthy baby and she is also healthy, I
feel rewarded.
In many instances, ASHAs advanced money for transportation and other medical expenses
out of pocket.
46
Table 18 :Themes from the Qualitative responses
Individual level
Motivated to help others
No basic facility to stay overnight at health facility
Lack ofawareness of birth preparedness components
Family Level
Lack ofsupport due to non — payment
Needforfrequent home visits deprive other means oflivelihood
Tensions within the family ifneeded to escort women at night
Community level
Lack ofawareness about blood donation
Irregular payment for transportfrom VHSCfunds
Lack ofsupport from community men during night
Illiteracy and ignorance ofhouse holds
Poverty stricken households
Lack ofawareness regarding ASHAs roles and responsibilities
Health system level
Multiple referral
Lack of blood bank facility
Delays in giving treatment to an obstetric emergency
Poor conditions at health facilities
Irregular supply ofIFA
Placement ofthe PHC
Irregular payment
Support from ANM
Lack ofappreciation from superiors
Certification issues at referral centers
Informal payments at the district hospital and other hospital staff in various facilities.
“Once a pregnant lady had to undergo C-section as baby was upside down, but the family
didn 7 agree to take the patient to the referral hospitalfor monetary reasons. I spent my
money and took the pregnant lady to the hospital. The doctor told me ifshe was not brought
47
immediately and C-section was not done the baby would not have survived. Ifelt much
rewarded. ”
At the same time, their motivation is dampened by the lack of basic facilities the health
system offers the ASHAs.
There is no facility tofor us to stay overnight with the pregnant woman in the hospital. We
are shooed off by the ANMs and the doctors. We take some bed sheet and sleep in the
corridors and wait till the woman delivers. We are left hungry because it is expensive for us
to buyfoodfrom outside. ”
Some were promised money if they had to stay overnight with the patient, but it was never
given.
Motivation was also dampened by the irrational way in which they were being held
responsible by health care providers should things go wrong.
“It is very difficultfor me to arrange blood if required. The zilla hospital does not have
blood. The doctors ask me to arrange bloodfrom Hospet which is veryfar 35/- by bus. They
also ask me to sign a paper saying if by the time blood comes, the lady dies it is my
responsibility. Ifeel very confused and scared during these times. ”
iL
Family and community level
Given that most of my respondents were young married women, the support from their
families was very important to carry on their responsibilities. It was seen that the ASHAs
almost always accompany woman to hospital. This required travelling long distance, staying
48
overnight and sometimes even longer. The demands of her work were creating tensions at
home. They felt that they would be called for at any time of the day to help woman and
children of her villages, so was not in a position to take up any other means of livelihood.
Irregular payment even after a month o’f work (discussed later in this section) deprived tne
ASHA of the support from her husband and in-laws to efficiently discharge her duties.
The ASHAs felt there needed to be awareness among the community in the villages that they
had a role of helping the pregnant women..
I want more support from the Grama panchayat member; these people are not very
cooperative to help me with the duties and timely release of VHSCfundsfor transport. ”
Often, little support was forthcoming even from the families of the pregnant women who the
ASHAs were helping.
“Around a year back I took a patient to the district hospitalfrom where the case
was referred to a private hospital. The patient’s husband also accompanied the
patient to the hospital. They said blood was needed. When the husband contacted
his family members in his village to come to donate blood, thefamily told him
nobody would give blood and he himself shouldn’t donate blood and asked to get
the patient back to the village immediately. It didn’t matter if the patient died or
survived. I tried convincing the husband but the husband was also not ready to
donate blood. I told him I would arrange blood myself. I called up my relatives to
come with some money and also asked them to donate blood. Two ofmy relatives
donated blood and saved the patient. This was very difficult and rewarding
49
experience for me. ”
The determination and motivation ASHAs showed which helped save a life is worth
applauding.
UL
Health system level
We examined the frequency and duration of interaction of ASHAs with their superiors as an
indicator of the extent of support that ASHAs received from the health system. For the
purpose of my analysis support from the ANM , Medical Officer and Anganwadi worker was
divided into three categories-
4. Optimal- If frequency >4 times per week and duration >2 hours or 1 -2 hours per
interaction
5. Moderate — If frequency 2-4 times per week and duration of <1 hour or 1 -2 hours or
> 2 hours per interaction and frequency >4 times per week and duration of <1 hour
per interaction.
6. Suboptimal - If frequency > 2 times per week and duration < 1 hours or 1 -2 hours or
2 hours per interaction
Table 19: Interaction with ANM, MO and AWW
Interaction
N=207
MO
N(%)
AWW
N (%)
11(5.3)
45(21.7)
151(72.9)
0
46(22.2)
91(44)
60(29)
10(4.8)
ANM
N (%)
Optimal__________ 57(27.5)
Moderate >_______ 103(49.8)
Suboptimal
47(22.7)
None
0
Source: Primary Survey ,2011
50
Since ANMs were the people to be contacted first and equally accessible in 204(98.6%) of the
cases, only the support from ANM is considered for further analysis. There may, however, be
exceptions to this. In the open-ended responses, one of the ASHAs said“Sometimes ANM is not cooperative, she (ANM) wants halfof the money what I get”.
It could be well understood that it is the quality of interaction and not the quantity which
matters. So, the question which was subsequently asked was, “What were the three areas of
discussion during interaction?”
It was reported that the areas of discussion with the ANMs were on topics of ANC
registration, recent births/deaths and fever cases among the households in the village in that
order of importance. In addition they reported to have discussed TB/Malaria cases, smear
taking for fever cases, counseling issues of ANC and PNC during home visits, immunization
of children in the descending order of importance.
The areas of discussion with the Medical officers were all complicated issues of pregnancy
such as need of blood, completion of all ANC checkups, certification issues including
payment problems and other health problem seen at their villages in that order of
importance. These discussions usually happened at the monthly meetings at the PHC.
The areas of discussion with the AWW were on immunization, weighing children and
organizing the health day at the Aaganwadi centers in that order of importance. They also
discussed new pregnancies and childbirths in their villages.
Narratives of ASHAs, however, pointed to many health-system created barriers to ASHAs
effective functioning. One of major demotivators was that ASHAS were not being paid
regularly. Irregular payment and not getting the initial promised amount for helping pregnant
51
woman was reported by almost all the respondents.
‘7 need regular payment. Because ofno money my husband wants me to quit thisjob as I even
have to go out at night
Informal payments in the form of bribes at the district hospital and by other hospital staff in
various facilities makes the task oif motivating women for institutional deliveries especially
hard.
‘Doctors need to cooperate and understand a poor woman’s condition; instead they askfor
bribes, so the patients are going to the RMPs. ”
ASHAs also seem to be at the receiving end from families for many health-system failures.
For example, the ASHA was held accountable by families for repeated referral from one
health facility to another, but ASHAs were not in a position to neither clarify nor understand
the reasons for referrals.
“Two months back, there was a pregnant woman with severe bleeding.. I called the 108 and
got the patient to the PHC, from here the case was referred to the district hospital. We took
the patient there, but no doctors were available and no treatment was given. Then we took her
to a private hospital. Some tests were done and the hospital said that the patient was severely
anemic. The patient was again referred to the Hospet 100 bed government hospital were only
saline was given. Then again referred to the Bellary district where the bleeding was brought
under control. Some injections and blood was also given. But the patient had no BPL card.
Thefamily was very poor. They had to spend 22,000/-, but JSY gave them 700/ ”
52
1
There was an instance when a respondent tries to help a difficult pregnancy and after much
persuasion takes the woman to a higher facility but the doctor who sees the patient is
unresponsive.
“Last month I brought a pregnant lady -with severe bleeding to the PHC, the doctor here
immediately referred her to CHC. I, husband and mother in law of the pregnant lady
accompanied her to the CHC. The doctor saw the patient gave her 2 injections and said he
had a very urgent meeting to attend and was a very tough casefor him to handle and left.
After the doctor left the patient was a severe pain, then the ANMput the gloves and helped her
deliver a healthy baby girl. ”
An interesting finding that stood out from the narratives was the quality of the ANC. There are instances
when breech position and blood groups of the pregnant woman were unknown till the time of delivery.
Also there were high levels of eclampsia cases.
There were several narratives indicative of pre-eclamp sia, eclampsia, eclamptic convulsions, ante-partum
hemorrhage and post- partum hemorrhage which are very well major causes of obstetric emergencies.
Why that is pre-eclampsia has not been detected in ANC? If pre- eclampsia is not detected then how does
one manage or let ASHA know what to do or how and what to counsel?
53
4.5 Bivariate Analysis
4.5.1 Factors associated with the knowledge scores of key danger signs
There was no difference in the knowledge scores of key danger signs as related to the
background variables such as age, marital status, education and child less than five years
However, the work related variables such as training, practical training and training in the
last three months the preceding the survey were significantly associated.
Table 20: Factors associated with the knowledge scores of key danger signs
Knowledge scores of the Key danger signs
Work Related
Characteristics
P
value
Total
0-3
N (%)
4-5
N (%)
6-7
N (%)
4(100)
4(44.4)
85(52.1)
21(67.7)
0
4(44.4)
64(39.3)
10(32.3)
0
1(11.1)
14(8.6)
0
89(65.4)
1(50)
24(34.8)
41(30.1)
1(50)
36(52.2)
6(4.4)
0
9(13)
.00*
136
2
69
13(37.1)
101(58.7)
17(48.6)
61(35.5)
5(14.3)
10(5.8)
.03*
35
172
24(35.8)
90(64.3)
35(52.2)
43(30.7)
8(11.9)
7(5)
.00*
67
140
<30 minutes
34(53.1)
24(37.5)_______ 6(9.4)
30-60 minutes
31(53.4)
21(36.2)
6(10.3)
61-120 minutes
31(57.4)
21(38.9)_______ 2(3.7)
>120 minutes
18(58.1)
12(38.7)_______ 1(3.2)
Source: Primary Survey, 2011 (*p value < 0.05 significant)
.80
64
58
54
31
Experience
6-12months
13-24months
25-36months
>36months
Training
1round
2 rounds
3-4 rounds
.24
4
9
163
31
Practical training
yes
no
Training in the
last 3 months
yes
no
Time to reach
nearest PHC
54
4.5.2 Factors associated with the Knowledge scores of essential components in ANC
There was no difference in the knowledge scores of essential ANC components as related
to the background variables such as age, marital status, education and child less than five
years. Never the less, work related characteristics such as experience, training, practical
training and training in the last three months preceding the survey were seen to be
significantly associated.
Table 21: Factors associated with the knowledge scores essential components of ANC
Work Related
Characteristics
Essential components of ANC
P
value
Score 2-6
N (%)
Score 7-8
N (%)
Experience
6-12months
13-24months
25-36months
>36months
2(50)
3(33.3)
74(45.4)
24(77.4)
2(50)
6(66.7)
89(54.6)
7(22.6)
Training
1 round
2 rounds
3-4 rounds
81(59.6)
1(50)
21(30.4)
55(40.4)
1(50)
48(69.6)
.00*
136
2
69
6(17.1)
97(56.4)
29(82.9)
75(43.6)
.00*
35
172
21(31.3)
82(58.6)
46(68.7)
58(41.4)
.00*
67
140
Practical training
yes
no
Training in the
last 3 months
yes
no
.00*
Time to reach
nearest PHC
<30 minutes
35(54.7)
29(45.3)
.21
35(54.7)
30-60 minutes
33(56.9)
25(43.1)
33(56.9)
61-120 minutes
23(42.6)
31(57.4)
23(42.6)
>120 minutes
12(38.7)
19(61.3)
12(38.7)
Source: Primary Survey ,2011 (*p value < 0.05 significant)
55
Total
4
9
163
31
64
58
54
31
4.5.3 Factors associated ANC service provision
There was no significant association between the knowledge levels of the respondents for
essential ANC activities and the corresponding service provision.
However the work related characteristics such as training, recent training and the ANM
support were significantly associated with ANC service provision.
Table 22: ANM support as associated with ANC service provision
ANC Service provision
ANM Support
2-5 Steps
6-8 steps
P
N (%)
N (%)
value
Optimal
32(56.1)
25(43.9)
.00*
Moderate
69(67)
34(33)
Suboptimal
11(23.4)
36(76.6)
Source: Primary Survey ,2011 (*p value < 0.05 significant)
56
Total
57
103
47
Table 23: Work Related Characteristics as related to ANC service provision
Work Related
Characteristics
as related to
ANC service
provision
Number of activities in ANC service provision
2-5 activities
N (%)
6 -8 activities
N (%)
P
value
Experience
6-12months
4(100)
0
.22
13-24months
6(66.7)
3(33.3)
25-36months
87(53.4)
76(46.6)
>36months
15(48.4)
16(51.6)
Training
86(63.2)
1 round
50(36.8)
.00*
2 rounds
1(50)
1(50)
3-4 rounds
25(36.5)
44(63.8)
Practical
training
18(51.4)
yes
17(48.6)
.47
no
95(55.2)
77(44.8)
Training in the
last 3 months
.00*
yes
23(34.3)
44(65.7)
51(36.4)
no
89(63.6)
Time to reach
nearest PHC
<30 minuter
35(54.7)______ 29(45.3)
.98
30-60 minutes
31(53.4)
27(46.6)
61-120 minutes
30(55.6)
24(44.4)
>120 minutes
16(51.6)
15(48.4)
Source: Primary Survey ,2011 (*p value < 0.05 significant)
Total
4
163
"IF
136
35
172
67
140
64
58
54
31
Birth preparedness service provision was seen to be significantly associated with the
knowledge score of Birth preparedness plan. Work characteristics such as experience.
training, practical training, recent training had a significant association with birth
preparedness service provision.
57
Table 24: Birth preparedness knowledge as related to birth preparedness service provision
Birth
preparedness
Knowledge
score
Birth preparedness service
provision activities
1-4 activities
N (%)
5-7 activities
N (%)
P
value
Score 4-7
2(66.7)
145(98.6)
1(33.3)
2(1.4)
.00*
Score 1-3
57(100)
0
Total
Score 8
3
147
57
Source: Primary Survey ,2011 (*p value < 0.05 significant)
4.5.4 Factors associated with provision of emergency transport, funds and blood
There was no significant association in the provision of emergency transport as related to the
birth preparedness knowledge score. However the work related characteristics such as practical
training and the time taken to reach the nearest PHC were seen to be significantly associated
with transport provision.
Similarly it was seen that a significant association existed between the birth preparedness
knowledge score and the subsequent funds and blood/blood donor provision. Training was
the only work related characteristic associated with blood/blood donor provision.
Table 25: Birth preparedness knowledge as related to blood/blood donor provision
Birth
Blood/Blood donor provision N(%)
preparedness
Knowledge score
NGO only /
Total
No
Doctor at
Only ASHA/
Dr + ASHA +
P
provision
PHC/CHC
ASHA+ Dr
NGO
value
Score 8
0
1(33.3)
1(33.3)
1(33.3)
Score 4-7
26(17.7)
81(55.1)
29(19.7)
11(7.5)
Score 1-3
19(33.3)
30(52.6)
6(10.5)
2(3.5)
Source: Primary Survey, 2011 (*p value < 0.05 significant)
58
3
.04*
147
57
rounds of training can definitely affect their knowledge competencies. The fact that recent
training made a difference to knowledge scores may be owing to the low educational status
of the ASHAs, and definitely highlights the special needs of the CHWs in Koppal and
similarly less developed districts.
Despite the overall low levels of knowledge of danger signs, a vast majority (>80%) of
ASHAs knew about post partum hemorrhage as a danger sign and also that it was life
threatening. This suggests that they were aware of scenarios which were routinely seen, but
did not know enough about danger signs which are unpredictable but equally life threatening.
It also signals that there is a need to focus on practical knowledge especially on identifying
danger signs, in taluka and district hospital settings.
Another related finding causing concern was that none of the ASHAs reported having
discussed the signs and symptoms of pregnancy related complications during home visits.
They lacked the most important lesson that training should or could have imparted, i.e.;
every pregnancy faces risks and being prepared for it is of paramount importance for better
maternal health outcomes. This study shows that neither the ASHAs nor the community were
aware that every pregnancy is risky and were not alerted to refer pregnant women to the
health facilities at the crucial stage. Then how could one expect better maternal health
outcomes? This is absolutely in agreement with the preexisting evidence that
acknowledgement of the emergency during pregnancy and the discussion on course of action
seldom happens in poverty stricken rural settings.33
Another finding which is in absolute agreement with the NHSRC 8 state evaluation9 is the
neglect of post partum care. None of the ASHAs were able to correctly mention the
60
frequency of post partum checkups and the advice for contraception was given by a meager
2.4% of the ASHAs.
The second objective of this study documents the extent of service provision during the ANC
period and delivery. The findings in this study for service provision is very similar to the
report of the 8 state evaluation by the NHSRC in 2011.9 The focus appears to be on providing
information on JSY benefits. Essential aspects of service provision during pregnancy were
neglected. Only 28% of the respondents actually calculated the date of delivery for the
pregnant woman, 42.5% provided IFA, 3.4% helped getting nutrition supplements from the
Aaganwadi centers. Even worse, only 1.4% identified an institution for referral and .5%
identified a blood donor.
As far as the findings of my third objective which explored the provision of emergency
transport, funds and blood donor, it was seen that the time taken just to arrange emergency
transport was greater than 30 minutes in 48.3% of the responses. The time taken to reach the
health facility took more than two hours for normal deliveries in 5.3% and in 24.2%
responses took more than two hours in cases perceived to be of high risk to reach the higher
health facility. This is no better than a previous study in Nepal that found 36% of families
who decided to seek care and got transport in 2 hours, 15 percent in 2- 2.5 hours.36
Though 65.7% helped mobilize funds for delivery, there were a quarter of ASHAs who had
no clue on blood donor or blood provision. Here too as emergencies were not anticipated,
time is wasted looking for funds, blood donor, transportation and the most appropriate health
facility as seen in Pakistan and Nepal.33,36
61
In contrast to an earlier study in South Asia which suggested that the reproductive health
education to the woman and their families were restricted due to weak / nonexistent linkages
between the community and the health system33 this study shows that though ASHA forms an
interface between the health system and the community, for various reasons the health
system is unsupportive and unresponsive.
For example, there were many indications of the poor quality of antenatal care in the
narratives of ASHAs. There were instances when breech position and RH negative blood
groups of the pregnant woman were unknown till the time of delivery. Also there were
several cases narrated indicative of pre-eclampsia, eclampsia and eclamptic convulsions. This
makes one wonder as to why pre-eclampsia was not detected in ANC, and raises questions
as to how ASHas can be expected to counsel and prepare for obstetric emergencies if there
were such lacunae in services.
Narratives of ASHAs also show that although they are highly motivated and strive to rise to
the challenge of saving maternal lives, the dysfunctional health care system in the district
thwarts their efforts in many ways: inadequate training, unresponsiveness of health providers,
informal payments, repeated referrals and lack of accountability to patients. Irregular
payments of their modest remuneration and lack of respect from health providers at various
levels add to these difficulties.
Thus it is seen that being an ASHA seems to be being in an unenviable position. She is
answerable to the community if things go wrong with women going through pregnancy and
delivery, but lacks the skills and knowledge as well as the supervisory and logistical support
62
from the health system. So, ASHA bears the brunt of both the health system and the
community.
5.2 Strengths of the study
1. The study is comprehensive in that the knowledge of the key danger signs, service
provision, supervisory and support aspects of CHWs on maternal health outcomes has
been explored.
2.
It was able to meet its aim and the objectives and provided an understanding of the
different factors that determine the birth preparedness and complication Readiness
practices at the level of ASHAs, community and to an extent the health system.
3. Qualitative part of the survey supplemented and illuminated the quantitative part making
the study more complete and relevant.
4. This study could serve as a baseline data, as evidence suggests that improvement in
knowledge levels can be very small when compared to all health care interventions so,
even small improvements in the area of knowledge of key danger signs can be regarded
as significant program achievements.
5. Data contamination was highly minimized as the ASHAs working in the same PHC/SC
were interviewed within a span of 2 days.
6. Since the data was collected by a single investigator, inter observer variability has been
avoided.
63
7. This study is a worst case scenario; meaning in a district which is placed at the bottom of
human development index in Karnataka, so the findings can be definitely generalized to
all the backward districts across India.
8. Right context and timing of the study -since six years with the launch of JSY and ASHAs
playing a role there was no study in the district of Koppal and in the state of Karnataka.
5.3 Limitations of the study
1. There may be a bias in the responses as the respondents were approached through the
health system.
2. The presence of a research assistant during the time of interview to help me translate the
local dialect may have biased the responses.
3. Follow up of study will be needed to further explore the caste class dimensions and the
other quahtative aspects explored.
5.4 Policy Recommendation
The government has no doubt taken steps toward implementing JSY that contribute to
decreased maternal and infant mortality and morbidity and also to women’s increased access
to comprehensive and affordable reproductive healthcare services. However, to continue on
this same track, operational policies need to be updated and new policies introduced. These
policies will ensure that access to services is expanded to further reduce maternal and
neonatal morbidity and mortality.
64
The data collected in this study suggest the following areas for policy change:1.
Targeting institutional deliveries is not the only solution for reducing MMR. The issue
more crucial is the identification of high risk pregnancies and giving them priority care.
ASHAs must be trained to identify women experiencing complications and to refer them
directly to the facility equipped to provide comprehensive Emergency Obstetric Care
(EmOC).
2.
Practical training at tahika (sub-district) and district showing ASHAs how to identify
signs and symptoms of complications during pregnancy , childbirth and post partum
period with lessons and practical training on immediate first aid, should to taken up
immediately by the concerned authorities. The focus should be on key danger signs.
3.
Training, practical training should be reinforced by repeated learning of the lessons
taught at least three monthly intervals considering the low educational status of the
ASHAs in the district.
4.
All ASHA supervisors including the ANMs and the MO should have a checklist
according to the work of the ASHAs. These should focus on problem solving depending
on the contextual factors affecting the service provision. These data should be also used
to understand the areas which need to be stressed during discussions and training.
5.
The regulation to supply uninterrupted medicines in particular IFA and timely
replenishment of ASHAs drug kit should be done.
6.
Lack and irregular payment of monetary benefits to ASHAs is seen as a major deterrent
to her work. Regular and timely payment to these workers will not deter the spirit of
these well motivated ASHAs.
65
7.
The promised Madilu kit which contains 19 items for mother and infant care for BPL /
Schedule Caste and Schedule Tribe families, 1st two live births and seen as an incentive
by many families should reach the needed uninterrupted.
In addition, many of the health system barriers that hinder ASHAs’ work also need to be
addressed.
8.
It is essential to increase the number of facilities offering comprehensive EmoC and to
improve quality of care by training providers at these facilities to offer timely care to
women with complications.
9.
With the number of AYUSH doctors manning the PHCs it becomes essential to train
them to handle obstetric emergencies to avoid irrational and multiple referrals.
10.
Blood banks needs to be started at all taluka (sub-district) level hospital and blood should
be made available free to all BPL families.
11.
Provision for scanning at the sub district hospitals and quality of the laboratory tests need
attention. The CHC infrastructure including uninterrupted power supply should be
stressed on.
12.
Strict regulation is required to handle corruption and rampant informal payments at
various health facilities.
13.
The provision of funds for fuel from the hospital in case the poor patients have to use the
hospital ambulance if 108 services are not available should be made.
14.
The provision for an over bridge construction at railway crossings to avoid delays
reaching the health facility should be eyed upon.
66
5.5 Conclusion
In conclusion, the ASHA cadre in India created to address the problem of high maternal
mortality has great potential given that they are a very large number, are in the prime of
their lives with a high level of motivation and are working at the grassroots.
Unfortunately, it is seen that the best motivated ASHAs in most situations will not be able to
save lives of women because their training misses out on all the key knowledge and skills
that the ASHAs need in order to save maternal lives. The health system does not provide
them with adequate back-up support and is ill-equipped and unresponsive overall. The need
of the hour is appropriate training for ASHAs located within a supportive, functioning and
responsive health system.
67
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74
Interview Schedule for ASHA
Identification No.
District
Block/PHC/CHC
Village
Name of the sub centre
Start Time
Q No.
Date
End Time.
Question
Options
JZJ________
_
information
1. Background
Code
of ASHA
1.
Name
2.
What is your age?
1.
2.
3.
4.
3.
What is your current marital status?
1. Single
2. Married
3. Widowed
4. Divorced
5. Separated
bi03
4.
Do you have children less than 5 years of
age?
1. Yes
2. No
bi04
5.
What is highest level of education you
have completed?
1. <10th standard
HZT
2. Completed 10th standard
3. 11th-12th standard
4. Post 12th Diploma/
certificate course
5. Graduation
6. Post Graduation
bi05
6.
Since when are you working as ASHA?
1.
6 months -12 months O
bi06
biOl
1
<30 years
30-39 years
40-49 years
>50 years
bi02
n
2. 13-24 months
3. 25-36months
4. >36 months
n
7.
How many rounds of training have you
received?
1.
2.
3.
4.
8
Did the training include any practical
content?
1. Yes
2. No
9.
If yes, where did you go for practical
training?
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
Did you receive any training in the last 3
months?
1. Yes
2. No
11
How long does it take from your home to
reach the nearest primary health centre?
1. <30 minutes
2. 30 minutes- 60minutes
3. Glminutes-120 minutes
4. >120 minutes
1 round
2 rounds
3-4 rounds
>4 rounds
bi07
bi08
Government district Hospital LJ
Taluka hospital
O
CHC
PHC
Sub centre
Private Hospital
O
Private Maternity Center
O
Home
0
Other(Specify) ——————
bi09
bi 10
n
bill
2. Pregnancy related - knowledge
12.
In your opinion,
what are some
serious health
problems that
can occur during
pregnancy that
could endanger
the life of a
pregnant
woman?
Key Danger signs
1. bleeding
|_ |
2. swollen hands/face O
3. blurred vision
O
2
Other Danger signs
convulsions
LJ
severe headache O
high fever
Q
loss of consciousness^
difficulty breathing J J
severe weakness
O
severe abdominal pain\ I
accelerated/ reduced fetal
movement I
9. water breaks without labor 0
10. other (Specify)-------------------
1.
2.
3.
4.
5.
6.
7.
8.
pkl2
All key danger signs+ OthersLP^
All Key danger signs0--------------Not all key danger signsO----------
13.
In your opinion,
could a woman
die from any of
above mentioned
problems?
Key Danger signs
1. bleeding
------ 1
----- 2
------ 3
swollen hands/face yes Q
no LJ
no 0
don't know O
2.
3.
blurred vision
yes O
no 0
don't know O
yes LJ
yes 0
no 0
don't know O
no 0
don't know O
yes 0
high fever
loss of consciousness yes 0
no 0
don't know O
I
no |_ |
no0
don't know O
yesD
no n
don't know |
yes I
no
don't know O
no 0
don't know |
no
don't know O
yes O
Other Danger signs
1. convulsions
2.
3.
4.
5.
6.
7.
8.
9.
severe headache
difficulty breathing
severe weakness
yes I
don't know |
pkl3
|
don't know O
|
severe abdominal
pain
I
accelerated/ reduced
fetal movement
yes 0
10. water breaks without
labor
yes 0
|
Other (specify/
__________
All key + other danger signs considered fata 10-------- 1
All Key danger signs considered fatal0-------------------- 2
other danger signs considered fata 10
■3
COMPONENTS OF
ANTENATAL CARE
(16)
OPTIONS
14
15.
In your opinion,
what are the
components of
antenatal care?
Essential
components to
reduce
complication in
pregnant
woman?
1. Regular weight
check______________
2. Blood test for
anemia____________
3. Urine test for
protein and sugar
4. Measuring blood
pressure___________
5.1 FA tablets
for3months_________
6. Nutrition education
ESSENTIAL
COMPONENTS
(17)
pkl4
pkl5
7. Two doses of
tetanus toxoid
immunization______
8. Hygiene education
3
9. Birth preparedness
plan
10. Complication
readiness
11. Others (Specify)-
16.
What
information do
you provide
while you visit
pregnant women
and their
families?
1.
That all pregnant women are at risk of developing
pregnancy related complications O
2.
That maternal complications are unpredictable but are
treatable
O
Importance of ANC visits
O
3.
4.
Discussions on plans for delivery (e.g. intention of where
to deliver, who the pregnant woman wants to be present
at her delivery, contingency plans in the event of
complications.
O
5.
Signs and symptoms of complications during pregnancy
and delivery
O
6.
Other (Specify)-----------------------------------All essential information provided I--------- -1
Some essential information provided\ I—
Most essential information not provided\Z\
17.
18.
How many
antenatal
checkups should
a pregnant
woman have?
When should a
pregnant woman
have the 1st
antenatal
checkup?
pkl6
1.
2.
3.
Three O
Four
>Four
1.
2.
3.
1st trimester O
2nd trimester O Correct answer\Z\----------- 1
3rdtrimesterO Incorrect onswerO----------- 2
2
-3
Correct Answe/O------- 1
Incorrect answer\ I------ 2
pkl7
Pkl8
3. Labor and Childbirth - Knowledge
19.
In your opinion,
what are some
serious health
problems that can
occur during labor
and childbirth
Other Danger Signs
Key Danger Signs
1.
Severe vaginal bleedinq\
2.
Prolonged labor
(> 12 hours)
Convulsions
3.
4
EZ
O
I
1.
severe headache O
2.
3.
high fever
loss of
consciousness
Ickl9
that could
endanger the life
of Pregnant
Woman?
4.
4.
Retained placenta beyond 30
minutes
O
Other (Specify)
All key danger signs+ OthersM------ -—-------- 1
All Key danger signsO------------------------- — 2
Not all key danger signsO-------------------- ----- 3
Key Danger Signs
20.
In your opinion,
could a woman
die from any of
these problems?
1. severe vaginal bleeding
2. labor lasting >12 hour
3. convulsions
4. retained placenta
beyond 30 minutes
don't know O
don't know O
don't know O
yesQ no
yesQ no
yesD no
lck20
yesD no I \don't know\ |
Other Danger Signs
1. severe headache
yes O no O
2. high fever
yesEH no O
3. loss of consciousness yesO no O
4. o ther(Specify)
don't know O
don't know O
don't know O
All key + other danger signs considered fataO
All Key danger signs considered fata I --------other danger signs considered fatalO— ■3
21.
In your opinion,
what are some
things a woman
can do to prepare
for birth?
-1
■2
Ick21
1. identify health facility
2. identify skilled provider
3. identify mode of transport
4. save money for delivery
5. save money for transportation
6. identify blood donor
7. identify the person who will escort to skilled careO
8. prepare clean items for birth
O
9. Others(Specify)----------------------------------------------
All essential information stated O------Some essential information stated O—
Most essential information not stated I I
4. Postpartum Care - knowledge
5
1
-2
3
22.
In your opinion,
what are some
serious health
problems that can
occur during the
first 2 days after
birth that could
endanger the life
of the woman?
Key Danger Signs
1. Severe vaginal bleeding[Z\
2. Foul-smelling vaginal\ I
discharge
3. High fever] I
1.
2.
3.
4.
5.
6.
7.
8.
All key danger signs+ Others! I—■
All Key danger signs! I-------------Not all key danger signsE]-------23.
In your opinion,
could a woman
die from any of
these problems?
pck22
Other Danger Signs
severe headache O
blurred vision
O
convulsions
LU
swollen hands/face O
loss of conscio usness\ I
difficulty breathing O
severe weakness
other(Specify)
-------- 1
2
-------- 3
Key Danger Signs
1. Severe vaginal bleeding
2. malodorous vaginal
discharge
3. high fever
yesD
pck23
no E] don't know O
yesD no O don't know Q
yesD no
don't know Q
Other Danger Signs
1. severe headache yesQ no |_J don't know O
2. blurred vision
yesO no
don't know O
3. convulsions
yes! I no
don't know O
4. swollen hands/face ye$O noQ don't know\ |
5. loss of consciousness yes! I no
don't know | |
6. difficulty breathing yesO no O don't know Q
don't know O
7. severe weakness yes! I no
8. other(Specify)
All key + other danger signs considered fatalO-------- 1
All Key danger signs considered fataO------------------ 2
other danger signs considered fataO------ 3
24.
25.
In your opinion,
how many times
should a mother
have postpartum
checkup after
child birth?
In your opinion,
during the
postpartum visit
what should you
advice the
mother?
1. Once at 3 weeks postpartum C l
2. Once, at 6 weeks postpartum O
3. 3 times: at 6 hours, 6 days, and
4. 6 weeks postpartum
O
5. Any time she has danger sign O
6. Only if she has danger signs O
7. Other(specify)-----------------------1.
2.
3.
4.
5.
pck24
Correct Answer! I—
Incorrect Answer\ I
Rest for at least 6 weeks LJ
Eat more food especially high protein foods
Exclusive breast feeding for 6 months! I
Need for contraception methodsn
Others (specify)----------------------------------------
6
1
-2
pck25
26.
In your opinion,
what things
would you advice
regarding
breastfeeding?
1. Start breastfeeding immediately
O
2. Breastfeed at least 8-10 times in 24 hours.I I
3. Baby should not be given any other foods for 6 monthsl I
4. Correct position for breastfeeding O
5. Others (specify)----------------------------------------------------
pck26
5. Antenatal Care service provision
27.
Which antenatal
services are you
expected to
provide to
pregnant women?
What is the actual
provision of
services in the last
1 month?
1. ANTENATAL CARE SERVICE
_______________ _____________
EXPECTED TO
ACTUAL
PROVIDE (a)
PROVISION (b)
1. Helping in registration for JSY
scheme/ for ANC services_____
2. Calculating date of delivery
asp27.1(a)
asp27.1(b)
3. Providing Home visits
4. Helping with at least 3 ANC
checkups________________
5. Facilitating TT injections
6. Providing Iron/Folate tablets
7. Invite them to attend health
day
8. Get nutrition supplements
from Aanganwadi center
9. Others(specify)
2. BIRTH PREPAREDNESS
SERVICE
ACTUAL
EXPECTED TO
PROVISION (b)
PROVIDE (a)
1. Counsel for institutional
delivery_________________
2. Explain cash assistance
benefits for institutional
delivery_________________
3. Explain transport assistance
benefits for institutional
delivery
4. Identify a functional
Government health centre or
an accredited private health
facility__________________
5. Identify Institution for
referral /delivery__________
6. Identify blood donor
7. Others (specify)
7
asp27.2(a)
asp27.2(b)
28.
Where do you
advise a pregnant
woman to go in
case of delivery.
;________________________
1. Government district Hospital
NORMAL
(a)
COMPLICATED
(b)
asp28
2. Taluka Hospital
3. CMC
4. PHC
5. Private Hospital_______
6. Private Maternity Center
7. Home______________
8. Other(specify)
29.
In general,
how long
would it take
to reach this
health facility?
asp29
NORMAL
(a)
COMPLICATED
NORMAL
(a)
COMPLICATED
(b)
asp30
NORMAL
(a)
COMPLICATED
(b)
asp31
(b)
1. Less than 30 minutes
2. 30 minutes - 60minutes
3. 61 minutes -120 minutes
4. More than 2 hours
30.
31.
32.
What is the
total cost of
transportation
from home to
facility?
In your
opinion, how
are the
services in this
facility? Would
you say they
are excellent,
good, average,
or poor?
Can you tell me
why you have
ranked the
services as above?
1. < Rs 200/2. Rs 201-500/3. >Rs 500/- ~
1. Excellent
2. Good
3. Average
4. Poor
5. Don't know
NORMAL(a)
1. doctor always there
2. facility always open
3. staff respond to my
questions________________
4. facility always has necessary
medicines/blood
5. not a long wait
8
COMPUCATED
(b)
asp32
b.
was in danger?
Where did you
take her?
asp35b
c.
How did you take
her there?
asp35c
d.
Who all
accompanied the
woman?_______
What services did
the woman
receive once she
arrived at the
facility?________
Can you think of a
most difficult
experience when
you dealt with a
complicated
pregnancy?Can you think of a
most rewarding
experience of
having
successfully
helped a pregnant
woman in your
community?
asp35d
e.
36.
37.
asp35e
asp36
asp37
6. Support mechanism & barriers
38.
39.
sb38
Do you feel rewarded
in your role as ASHA?
If yes, What makes you
feel rewarded about
being ASHA?
1. Yes
2. No
1.
2.
3.
4.
5.
6.
recognition in community
I_ |
Ability to make a difference in other women's livesO
Being able to help others
O
Opportunity to learn new thing
O
Appreciation from superior
O
Others(Specify)--------------------------------------
10
sb39
40.
What can be done to
making you
communicate more
effectively with
pregnant woman?
sb40
1.
2.
3.
4.
5.
41.
42.
Whom do you first
contact when you have
difficulty in interacting
with pregnant woman?
Who is more accessible
to you?
Provision of Flip book / Chart / Posters
O
Support from ANM/AWW during home-visit O
On job support for conducting counseling sessions at
AWC/VHND
Support for conducting group meetings / counseling
sessions
C
Other (Specify)
sb41
1. Aaganwadi worker O
2. ANM
3. Medical officer
O
4. Others(specify)---------
1. Aaganwadi worker O
2. ANM
3. Medical officer
El
4. Others(specify)---------------------
11
sb42
43
What is the nature of
your interaction with
ANM, medical officer at
the health facility with
respect to pregnant
woman?
Supervisor
Frequency
Duration
Location
Three areas
where most time
is spent
sb43
1.
ANM (a)
2.
3.
1.
Medical
officer (b)
2.
3.
1.
Others (c)
2.
3.
44.
Where you feel you
need more support in
helping
Pregnant woman of
your community?
sb44
12
Appendix 2
Annexure-1
Role and responsibilities of ASHA under Janani Suraksha Yojna
(Related to ANC services to pregnant women only)
The Janani Suraksha Yojana has identified ASHA, the accredited social health activist
as an effective link between the Government and the poor pregnant women in IO low
performing states, namely the 8 EAG states and Assam and J&K and the remaining NE
States. In other eligible states and UTs, wherever, AWW and TBAs or ASHA like activist
has been engaged in this purpose, she can be associated with this Yojana for providing
the services. Role of ASHA or other link health worker associated with JSY would be to:
ar
oy
y
y
Identify pregnant woman as a beneficiary of the scheme and report
or facilitate registration for ANC,
Assist the pregnant woman to obtain necessary certifications
wherever necessary,
Provide and / or help the women in receiving at least three ANC
checkups including TT injections, IFA tablets,
Identify a functional Government health centre or an accredited
private health institution for referral and delivery,
Counsel for institutional delivery,
Tracking Each Pregnancy: Each beneficiary registered under this Yojana should have
a JSY card along with a MCH card. ASHA/AWW/ any other identified link worker under
the overall supervision of the ANM and the MO, PHC should mandatorily prepare a
micro-birth plan. Please see Annexure -1. This will effectively help in monitoring
Essential Strategy
•
•
It should be ensured that ASHA keeps track of all expectant mothers
and newborn. All expectant mother and newborn should avail ANC and
immunization services, if not in health centres, atleast on the monthly health
and nutrition day, to be organised in the Anganwadi or sub-centre:
o
o
o
o
Each pregnant women is registered and a micro-birth plan is
o
prepared (please see Annexure-1)
Each pregnant woman is tracked for ANC,
o
For each of the expectant mother, a place of delivery is pre
o
determined at the time of registration and the expectant mother is
informed,
o
A referral centre is identified and expectant mother is informed,
14. Monitoring by ANM
14.1 Monthly Meeting at Sub-centre Level: For assessing the effectiveness of the
implementation of JSY, monthly meeting of all ASHAs / related health link workers
working under an ANM should be held by the ANM, possibly on a fixed day (may be on
the third Friday) of every month, at the sub-center or at any of Anganwadi Centres falling
13
under the ANM’s area of jurisdiction. If Friday is a holiday, meeting could be held on
following working day.
14.2 Prepare Monthly Work Schedule: In the monthly meeting, the ANM, besides
reviewing the current month’s work vis-^-vis envisaged activities, should prepare a
Monthly Work Schedule for each ASHA I village level health worker of following aspects
of the coming month:
Feed back on previous month’s schedule (a) Number of pregnant women missing ANCs,
(b) No. of cases, ASHA/link worker did not accompany the pregnant
women for Delivery,
(c) Out of the identified beneficiary, number of Home deliveries,
(d) No. of post natal visits missed by ASHA,
(e) Cases referred to Referral Unit (FRU) and review their current health
status,
(f) No. of children missing immunization.
Fixing Next Month's Work Schedule (NMWS): To include (i)
(ii)
(iii)
(iv)
(v)
(vi)
(vii)
(i)
Names of the identified pregnant women to be registered and to
be taken to the health center/Anganwadi for ANC,
(ii)
Names of the pregnant women to be taken to the health center for
delivery (wherever applicable),
(iii)
Names of the pregnant women with possible complications to be
taken to the health center for check-up and/or delivery,
Names of women to be visited (within 7 days ) after their delivery,
(iv)
List of infants / newborn children for routine immunization.
(v)
To ensure availability of imprest cash,
(vi)
Check whether referral transport has been organized.
(vii)
Annexure-I
Annexure -1 MICRO-BIRTH PLAN FOR JSY BENEFICIARIES
STEP
Activity
To be undertaken by
1.
Identification and
Registration of
beneficiary
ANM/ASHA/AWW or
any link worker
2.
Filling up of Maternal ANM/ASHA/AWW or
and Child card ( In
an
equivalent link worker
duplicate — one each
for
mother and
ASHA/Link
worker)
(This will form part
of the
JSY’S Registration
14
Proposed Time
Line__________
At least 20-24
weeks before the
expected date of
delivery._______
Immediately on
registration
Card).
3.
4I-s’:
Inform dates of 3
ANC&
TT Injection (s)
Identify the health
center
for all referral
Identify the Place of
Delivery
Inform expected date
of
delivery
4.
Collecting BPL or
necessary proofs
/certificates
ANM/ASHA/AWW or
an
equivalent link worker
Immediately on
registration
Provide the 1st
ANC
immediately on
Registration.
ASHA to follow up the
ANCs at the Anganwadi
Centres/Sub-center (SC)
and ensure that the
beneficiary attends the
SC/Anganwadi centre
ZPHC for ANC on the
indicated dates
Motivation: ANM
should call the
beneficiary to the
Anganwadi/SC to
participate in the
Monthly
meeting and explain
enhanced cash and
Transport assistance
benefits for Institutional
delivery._____________
ANM/ASHA/AWW or
an
link worker
Within 2-4 weeks
from Registration
Wherever necessary
from
5.
Panchayat / local
bodies /
Municipalities_____
Submission of the
completed JSY card
in
the Health center for
verification by the
authorized/Medical
officer.
IL Take necessary
MO, PHC
ANM/ASHA/AWW/link
Worker
15
At least 2-4
weeks
before the
expected date of
delivery
steps
toward arranging
transport or making
available cash to the
beneficiary to come
to the Health Centre
III. Ensure
availability of
fund to ANM/Health
worker/ASHA etc.
Payment of cash
benefit
/ incentive to the
mother
and ASHA
6.
ANM/ MO, PHC
ANM/ MO, PHC
At the institution.
For complicated cases orthose requiring cesarean section etc:
Ac -1
Ac -2
Ac -3
Ac-4
Pre-determine a Referral health center By ANM/ASHA/link worker
and intimate the pregnant women_____
Familiarize the woman with the referral ANM/ASHA/link worker
centre, if necessary carry a letter of
referral from MO PHC______________
Pre-organize the transport facility in ANM/ASHA/Community
consultation
with
family
members/community leader_________
Arrange for the medical experts if the MO, PHC
same is not available in the referred
heath center
(Source of information Ministry of Health and Family Welfare website on NRHM
http: Z/mohfw. nic. in/do lw%20website/JS YfeaturesF AQ_No v_2006. htm)
16
Competencies to be developed in ASHA after 20 Days of Training
Appendix 3- Annexe 2-D Operational guidelines on maternal and newborn health
Competencies
General
Competencies
Maternal Care
Knowledge required______
□ Knowledge about
qualities that need to be
inculcated to successfully
work as ASHA
□ Knowledge about
village and its dynamics
□ Clear understanding of
role and
responsibilities
□ Understanding of who
are the marginalised
and the specif! c role in
ensuring that they are
included in health services
□ Key components of
antenatal care and
identifi cation of high risk
mothers
□ Complications in
pregnancy that require
referral
□ Detection and
management of anaemia
□ Facility within reach,
provider availability,
arrangement for transport,
escort and payment
□ Understanding labour
processes (helps to
understand and plan for safe
delivery)
□ In malaria endemic
areas, identify malaria in
ANC and refer
appropriately
□ Understanding obstetric
emergencies and
readiness for emergencies
including referral
17
Skill required___________
□ Conducting a village
level meeting
□ Communication skills especially
interpersonal
communication and
communication to small
groups
□ Skill of maintaining
diary, register and drug
stock card.
□ Tracking benefi ciaries
and updating MCH/
Immunisation card._______
□ Diagnosing pregnancy
using Nishchay kit
□ Determining the Last
Menstrual Period (LMP)
and calculating Expected
Date of Delivery
(EDD)
□ Tracking pregnant
women and ensuring
updated Maternal Health
Cards for all eligible
women
□ Developing birth
preparedness plans for the
pregnant woman.
□ Screening of pregnant
woman for problems
and danger signs and
referral
□ Imparting a package of
health education with
key messages for pregnant
women
□ Attend and observe
delivery and record various
events
□ Recording pregnancy
outcomes as abortion,
live births, still birth or
Home-Based
Newborn Care
Sick Newborn
Care
newborn death)
□ Recording the time of
birth in Hrs, Min and
Seconds, using digital wrist
watch__________________
□ Components of essential □ Provide normal care at
birth (dry and wrap
newborn care
□ Importance of early and the baby, keep baby warm
exclusive
and initiate
breastfeeding
breastfeeding)
□ Common problem of
□ Observation of baby at
initiating and
30 seconds and 5
maintaining breastfeeding
minutes for movement of
which can be
limbs, breathing and
managed at home
crying
□ Signs of ill health or a
□ Conduct examination of
risk in a newborn
new bom for
abnormality.
□ Provide care of eyes and
umbilicus
□ Measure newborn
temperature
□ Weigh newborn and
assess if baby is normal or
low birth weight
□ Counsel for exclusive
breastfeeding
□ Ability to identify
hypothermia and
hyperthermia in newborns
□ Keep newborns warm
□ Knowledge of risks of
□ Identify low birth
pre-term and low birth
weight and pre-term babies.
weight.
□ Care for LBW, pre-term
□ Knowledge of referral
babies
of sick newborns - when
□ Identify birth asphyxia
and where?
(for home deliveries)
and manage with mucus
extractor
□ Manage breastfeeding
problems and support
breastfeeding of LBW/Preterm babies
□ Identifi cation of signs
of sepsis and
symptomatic management.
□ Diagnose newborn
sepsis and manage it with
cotrimoxazole
18
Appendix 4- Annexe 3: Format for Individual Plans
(Birth Preparedness
Name:
Age:
Husband’s name:
HH income
LMP
EDD
Past pregnancy history (Include abortion, if any) :
Ord^r:
pregnancy
I
Date of
delivery
(Month and
Year}
Place of
delivery:
Home, SC,
PHC, CHC,
DH,
Private
Nursing
Home
Type of
delivery:
Natural,
Forceps,
C-Section
Birth
Outcome:
Live Birth,
Stillborn,
pnyorhe,
Age and
Status of
complications:
child currently Fever, Bleeding
First
Second
Third
• Any risk factors:
• Nearest SBA: Phone:
• Nearest 24X7 PHC: Distance: Time: Cost
• Nearest Sub-Centre with a Skilled Birth A0 endant
• Nearest CHC with facilities to manage complications: Distance:
Time: Cost
• Distance to District Hospital:
• How much is transport going to cost?
• Is the vehicle fixed:
Owner:
Phone No.:
• Will we need extra money for the treatment? How to organize it?
• Who will take care of the children when mother goes to the facility?
• Who will accompany her to the facility?
• Where will they stay?
• How will they finance their stay?
• Have they organized clothes and blankets for the ba
19
Appendix 5 - Informed consent
BIRTH PREPAREDNESS AND COMPLICATION READINESS OF ASHAs UNDER THE
SAFE MOTHERHOOD INTERVENTION PROGRAMME OF NRHM
RESEARCH SUBJECT INFORMATION SHEET
This study is being carried out as part of the course requirement for post-graduate studies
(Masters in Public Health) in Achutha Menon Center for Health Science Studies, Sree Chitra
Tirunal Institute for Medical Sciences, Trivandrum which I am currently undertaking. This
consent form may contain words that you do not understand. Please ask me if any words or
information is not clearly understood by you.
Purpose of the Study
ASHAs are first person in a community to be contacted for any health related problems,
especially of women and children. You have undergone training to create awareness,
promote good health practices and counsel women on birth preparedness, importance of
safe delivery in your community. Training also helps you to promote institutional deliveries,
through provision of referral, transport, and escort services in order to have healthy
outcomes of pregnancy and childbirth.
This survey is carried out to understand whether the trainings you receive, help you to
strengthen your knowledge and skills and the support you get from higher authorities is
adequate to carry out your assigned tasks. These findings will be used to provide feedback
to the authorities about aspects that are done well and suggestions for aspects that can be
improved.
You have been chosen through a random or chance process of selection much like picking an
orange out of a basket without looking. A total of about 225 subjects will be included and
interviewed as part of this study.
Procedure
The interview would take approximately 30 - 45 minutes of your valuable time. You will be
asked questions in private. The questions asked will be on your background information,
20
and knowledge based, related to pregnancy, childbirth and immediate post birth care,
antenatal services, and the provision of the same. Also, some questions pertaining to the the
type of support you receive or would want to receive to carry out your tasks will also be
asked.
This collected data will be used for research purposes only. I may contact you again if the
collected information was found to be incomplete. If you choose not to participate, this
decision will not affect your employment at this health facility in any way.
No information about your scores on knowledge questionnaires will be shared with your
supervisor or colleagues, nor will it affect your job status.
Benefits
There may not be any direct benefit for you from this study. The information collected from
you and from other participants will help to provide some general feedback to the facility
about aspects that are done well and suggestions for aspects that can be improved.
Confidentiality
You will be interviewed in private. All information related to you will be kept confidential
and at no stage will your identity be revealed. A respondent identification number will be
assigned to each participant that will help in maintaining the confidentiality of the data
collected. Access to this number will be restricted to those analyzing the data only.
Contact Information
If you have any research related questions, you may contact me or any of the below
mentioned persons at the following address:
Dr.Smitha P.K
Dr.T.K Sundari Ravindran
Dr. Anoop kumar.T
MPH scholar 2010, AMCHSS
ProfessoMMCHSS, SCTIMST
Member Secretary,
SCTIMST, Trivandrum-11
Trivandrum -11
Cell: 09495391378
Tel: 0471-2524233
Institute
SCTIMST
Ethics
Trivandrum
Tel:0471-2520256
21
Committee,
Voluntary Participation
Your participation in this study is purely voluntary which means you can decide whether to
participate in the study or not. You can refuse to answer any question I ask. If at any stage
you wish to discontinue, you are free to do so without any adverse consequences. You can
also refuse to participate in the study entirely.
Date:
Interviewer's Name with signature:
22
BIRTH PREPAREDNESS AND COMPLICATION READINESS OF ASHAs UNDER THE SAFE
MOTHERHOOD INTERVENTION PROGRAMME OF NRHM
CONSENT FORM
I have read / been read out the information in the information sheet. The nature of the study
and my involvement has been explained and all my questions have been answered
satisfactorily. By signing this consent form, I indicate that I understand what will be
expected from me and that I am willing to participate in this study. I know that I can
withdraw at any time. I have been informed who should be contacted if the need arises.
Respondent’s Name:
Respondent’s Signature
Date:
23
Position: 4642 (1 views)