Skills that Save Lives

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2 ASHA Module 6 Skills that Save Lives Being an ASHA 1 Part A

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4 Contents PART A: Being an ASHA 5 1. Role of ASHA 7 2. Activities of an ASHA s 8 3. Measurable Outcomes of the ASHA Programme 9 4. Essential Skills for an ASHA Qualities that Make an ASHA Effective Conducting a Home Visit Village Health and Nutrition Day (VHND) What Records do the ASHA Maintain ASHA Support and Supervision 18 PART B: Maternal Health Pregnancy Diagnosis Birth Preparedness for a Safe Delivery Management of Anaemia Identifying complications during Pregnancy and Delivery Care during Delivery Post-Partum Care 38 PART C: Newborn Health Care of the Baby at the time of Delivery Schedule of Home Visits for the care of the Newborn Examining the Newborn at Birth Breastfeeding Keeping the Newborn Warm Management of fever in newborn 60 Annexes 61 Contents 3

5 About this book The sixth and seventh modules cover areas whose content is already familiar to the ASHA. In addition, this module includes the development of specific competencies in healthcare for mothers and children. It is thus, intended to serve as a refresher module, building on existing knowledge and the development of new skills in the area of maternal and child health. ASHAs that are newly recruited into the programme, could directly start with Module 5, 6 and 7. This module is also designed to serve as a reading material for ASHAs, and is therefore, to be given to each ASHA. A companion communication kit for the ASHA to use when she conducts home visits and village meetings has also been developed. There is also a manual for trainers with training aids to use during the training of ASHA. The training plan envisages a total of 20 to 24 days of residential training, to impart the skills that these two modules are teaching. Acknowledgements The sections on maternal and newborn care are excerpted from the SEARCH Manual on How to Train ASHA in Home-Based Newborn Care and SEARCH developed ASHA Reading Material on Home-Based Newborn Care. Thanks are due to Members of the National ASHA Mentoring Group, United Nations Children s Fund (UNICEF), Breastfeeding Promotion Network of India (BPNI), the Public Health Resource Network (PHRN), and the training, maternal and child health and malaria divisions of the ministry for providing extensive feedback, and also HLFPPT for providing information on Nischay Kit. The Integrated Management of Neonatal Childhood Illnesses (IMNCI) package is also incorporated into these modules. ASHA Module 6 4 Simple Skills that Save Lives

6 PART A Being an ASHA

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8 PART A Being an ASHA Objectives of this Session By the end of this session, the ASHA will learn about: The role of an ASHA and the activities expected of her. The health outcomes that her work should result in. The sets of skills that she needs to be effective in. The records that she has to maintain. The arrangements for her support and supervision. 1. Role of ASHA ASHA is considered to be a healthcare facilitator and provider of a limited range of healthcare services. Health rights would be integral to her work and would be focused in the areas of community mobilisation to improve health status, access to services, and promote people s participation in health programmes. Didi, which day is the ANM coming to our village? This is the first day of diarrhoea. Do I have go to the far away town or is there something you can suggest? Didi, they are charging me at the govt hospital and I don t have the money to pay can you help me? Part A Being an ASHA 7

9 2. Activities of an ASHA s ASHA s work consists mainly of five activities: 1. Home Visits: For two to three hours every day, for at least four or five days a week, the ASHA should visit the families living in her allo ed area. Home visits should take place at least once in a month if not more. Home visits are mainly for health promotion and preventive care. Over time, families will come to her when there is a problem and she would not have to go so o en to their houses. Meeting them anywhere in the community/ village is enough. However, where there is a child below two years of age or any malnourished child or a pregnant woman, she should visit the families at home for counselling them. Also, if there is a newborn in the house, a series of five visits or more becomes essential. 2. A ending the Village Health and Nutrition Day (VHND): On one day every month, when the Auxiliary Nurse Midwife (ANM) comes to provide immunisation and other services in the village, ASHA will promote a endance by those who need the Anganwadi or ANM services and helps with service delivery. 3. Visits to the health facility: This is usually accompanying a pregnant woman or some other neighbour who requests her services for escort. The visit could also be to a end a training programme or review meeting. In some months, there would be only one visit, in others, there would be more. 4. Holding village level meeting of women s groups, and the Village Health and Sanitation Commi ee (VHSC), for increasing health awareness and to plan health work. 5. Maintain records which would make her more organised and make her work easier, and help her to plan be er for the health of the people. The first three relate to facilitation or provision of healthcare and the last two are supportive and mobilisational activities. ASHA Module 6 8 Simple Skills that Save Lives

10 3. Measurable Outcomes of the ASHA Programme In the course of conducting these five activities, the ASHA should ensure the following: Maternal Health 1. That every pregnant woman and her family receive health information for promotion of appropriate healthcare practices diet, rest and for increased use of services which would focus on care in pregnancy, delivery, postnatal care and family planning services. 2. That every pregnant woman avails of antenatal care and postnatal care at the monthly health worker clinic/vhnd. 3. That every family with a pregnant woman has made a plan and is prepared for the event of childbirth. 4. That every couple that needs contraceptive services is counselled on where to avail of the service. Newborn and Child Health 1. That every newborn is visited as per the schedule, more o en if there are problems and receives essential home-based care as well as appropriate referral for the sick newborn. 2. That every family receives the information and support it needs to access immunisation. 3. That all families with children below the age of two years are counselled and supported for prevention and management of malnutrition and anaemia and for prevention of illness such as malaria, recurrent diarrhoea and respiratory infection. 4. That every child below five years with diarrhoea, fever, Acute Respiratory Infection (ARI) and worms, brought to her a ention is counselled on whether referral is immediately required or whether, given the problems of access to a doctor, first contact curative care with home remedies and drugs in her kit, the child can be managed. Disease Control 1. That those individuals noticed during home visits as having chronic cough or blindness or a skin patch in a high leprosy block are referred to the appropriate centre for further check-up. 2. That those prescribed a long course of drugs for tuberculosis or leprosy or surgery for cataract are followed up and encouraged to take the drugs or go for surgery. 3. That those with fever which could be malaria (or kala azar) have their blood tested to detect the disease and provide appropriate care/referral. 4. That the village and health authorities are alerted to any outbreak of disease she notes during her visits. Note: Each outcome is not a separate activity. They are part of the protocol followed during a single activity _ the home visit. Part A Being an ASHA 9

11 4. Essential Skills for an ASHA The essential skills that an ASHA requires can be classified into six sets. These are simple skills requiring only a few hours to learn, but they can save thousands of lives. These six sets of skills are given below: 1. Maternal Care a. Counselling of pregnant women b. Ensuring complete antenatal care through home visits and enabling care at VHND c. Making the birth plan and support for safe delivery d. Undertaking post-partum visits, Counselling for family planning. 2. Newborn Care when visiting the newborn at home: a. Counselling and problem solving on breastfeeding b. Keeping the baby warm c. Identification and basic management of LBW (Low Birth Weight) and pre-term baby d. Examinations needed for identification/first contract care for sepsis and asphyxia 3. Child Care a. Providing home care for diarrhoea, Acute Respiratory Infections (ARI), fever and appropriate referral, when required b. Counselling for feeding during illness c. Temperature management d. De-worming and treatment of iron deficiency anaemia, with referral where required e. Counselling to prevent recurrent illness especially diarrhoea. ASHA Module 6 10 Simple Skills that Save Lives

12 4. Nutrition a. Counselling and support for exclusive breastfeeding b. Counselling mothers on complementary feeding c. Counselling and referral of malnourished children. 5. Infections a. Identifying persons whose symptoms are suggestive of malaria, leprosy, tuberculosis, etc. during home visits, community level care and referral b. Encouraging those who are put on treatment to take their drugs regularly c. Encouraging the village community to take collective action to prevent spread of these infections and individuals to protect themselves from getting infected. 6. Social Mobilisation a. Conducting women s group meetings and VHSC meetings b. Assisting in making village health plans c. Enabling marginalised and vulnerable communities to be able to access health services. In addition, there are important skills related to self-awareness, communication, and organising a meeting which have been already taught in Module 5. Part A Being an ASHA 11

13 5. Qualities that Make an ASHA Effective For an ASHA to be effective in improving people s access to health services and their health status, an ASHA should: Have the knowledge and skills to explain the basic maternal and child health services, educate on preventive and promotive aspects of maternal and child health, and provide some measure of immediate relief and advice if there is any illness. Have the knowledge and skills on other general health issues, especially related to common infections, and be able to provide information on access to services and preventive and promotive aspects of healthcare. Be friendly and polite with people and known among community, and establish rapport with the family during household visits. Be a special friend to the needy, the marginalised, and the less powerful. Possess the art of listening. Have the skill of coordination with Panchayati Raj Institution (PRI), AWW and ANM. Be competent in conducting meetings in the community. Be motivated and feel happy and rewarded to help community/serve people. Have a positive a itude and be keen to learn new skills. ASHA Module 6 12 Simple Skills that Save Lives

14 6. Conducting a Home Visit The purpose of the home visit is to interact with the family, especially the young women of the house, so as to develop a rapport with them, communicate key health messages, support them for be er healthcare practices, identify illness early and provide appropriate advice. In particular, homes with a pregnant woman, or a woman who had an abortion or delivery within the last one month, or with any child below two or any malnourished child needs regular home visits. The first step is to gather information to understand the situation. You should ask appropriate initial questions, listen to the woman s response actively, and do not interrupt the woman while she is speaking. Once the mother has finished, ask further questions to clarify what she has said. Then seek more information by asking more detailed and probing questions about the duration of illness and the symptoms. The second step a er listening is to first praise the mother for how she is managing and reinforce the correct actions she is taking. Then make suggestions to the mother/woman on what further she needs to do in short sentences and in clear blocks of information. Repeat the key information to make sure that the mother has understood it. You should ask whether the All Visits (Basic communication skills to create friendly environment) Greeting. Explain why she is visiting today. Act in a way so family feels they can confide in her. Speak in a gentle tone. Use simple words in local language. Be respectful. Praise what the woman is doing correctly and build up her self-confidence. Point out why you are discouraging some health practices; do not merely condemn it or brand it as bad, superstition etc. Ask, don t tell. Check if the woman has any questions. Answer in simple language. Thank the woman after the visit and inform the family when you (ASHA) will return. Part A Being an ASHA 13

15 suggestion is applicable and acceptable, and whether she would be able to implement it. If necessary, ask the woman to repeat what has been suggested. Discuss further and come to an understanding of what can be done Then the third step, you should discuss and try to correct any misconceptions or rumours. Finally, you should also arrange for follow-up visit or referral. Do NOT prescribe health advice: You need to counsel. See the examples below: Gratuitous Ineffective Messages To prevent diarrhoea, pay attention to cleanliness. Take good care of the child. Your child is now one year old. You must give it nutritious food. Useful Health Communication Message To prevent diarrhoea, please ensure that you wash your hands with soap and water before preparing food or feeding the child and after cleaning up after defecation. Are you able to find enough time to feed the child? To play with the child? Who looks after the child when you are at work? Would it be possible for you to give your child an egg daily (or milk, green vegetables etc)? How would you manage it? Can you afford it? Would other children in the family also demand it, and would that create a problem? Difficult Situations If the woman is shy Speak of general things to warm her up. Encourage the woman to speak. Praise the woman more to make her confident. Repeat the questions. If the woman is non-cooperative or argumentative Praise the women to make her feel secure. Sympathise with her and be friendly; do not get angry. Spend more time in listening to her. Do not push if the woman is still not immediately receptive but just say that you would like to come again. If the woman is curious and asks many questions Answer her questions in simple language. Explain that you will be coming every month so they can talk again. ASHA Module 6 14 Simple Skills that Save Lives

16 7. Village Health and Nutrition Day (VHND) VHND is a common platform for allowing the people to access the services of the ANM and the male health worker and of the Anganwadi Centre (AWC). It is held at the AWC once every month. The ANM gives immunisation to the children, provides antenatal care to pregnant women and provides counselling and contraceptive services to eligible couples. In addition, the ANM provides a basic level of curative care for minor illness with referral where needed. The VHND is an occasion for health communication on a number of key health issues. It should be a ended by the members of the PRI, particularly the women members, pregnant women, women with children under two, adolescent girls and general community members. The VHND is to be seen as a major mobilisation event to reinforce health messages. You should provide information on the topics given below during the VHND. These topics can be taken up one by one and completed over a period of one year. Topics for Health Communication during the VHND Care in pregnancy, including nutrition, importance of antenatal care and danger sign recognition. Planning for safe deliveries and postnatal care. Exclusive breastfeeding and the importance of appropriate complementary feeding. Immunisation: the schedule and the importance of adhering to it. Importance of safe drinking water, hygiene and sanitation, and discussion on what actions can be taken locally to improve the situation. Delaying the age at marriage, postponing the first pregnancy and the need for spacing. Adolescent health awareness, including nutrition, retention in school till high/higher secondary level, anaemia correction, menstrual hygiene and responsible sexual behaviour. Prevention of Malaria, TB and other communicable diseases. Awareness on prevention and seeking care for RTI/STI and HIV/AIDS. Prevention of tobacco use and alcoholism. What should you do for a successful VHND? Make a list of the following and ensure their presence during the VHND meeting: Pregnant women for their antenatal or postnatal care. Part A Being an ASHA 15

17 Women who need to come for ANC for first time or for repeat visit. Infants who need their next dose of immunisation. Malnourished children. TB patients who are on anti-tb drugs. Those with fever who have not been able to see a doctor. Eligible couples who need contraceptive services or counselling. Any others who want to meet the ANM. Specially identifying families who are new migrants, living in hamlets or are vulnerable because of poverty or otherwise marginalised and ensuring their a endance. Coordinate with the AWW and the ANM to know in advance which day the VHND is scheduled so as to inform those who need these services and the community, especially the VHSC members. Undertake a part of the health communication work done at the VHND. ASHA Module 6 16 Simple Skills that Save Lives

18 8. What Records do the ASHA Maintain a. Village Health Register b. ASHA Diary c. Drug Kit Stock Register a. Village Health Register in which you will record details of pregnant women, children, 0-5 years, eligible couples and others in need of services. b. An ASHA diary which is a record of your work and also useful for tracking performance based payments due to you. c. Maintaining drug kit stocks: You are provided with a drug kit so as to be able to treat minor ailments/problems. The drug kit contains: Paracetomol tablets, Albendazole tablets, Iron Folic Acid (IFA) tablets, Chloroquine tablets, Oral Rehydration Salts (ORS), and eye ointment. In addition, the kit may contain condoms and oral contraceptive pills, pregnancy testing kits, and malaria testing kits. The contents of the kit may change depending on the needs of the state. The drug kit is to be re-filled on a regular basis from the nearest PHC. To keep a record of consumption of the drugs, and for effective re-filling and ensuring adequate/timely availability, a drug kit stock card is maintained. This can be completed by the person who refills the kit or by you. (Annexe 1: Sample drug kit stock card) Part A Being an ASHA 17

19 9. ASHA Support and Supervision For ASHA to be effective and for her skills to be updated, she needs both on-the-job support and refresher trainings. Each ASHA will be supported in the field by an ASHA facilitator. The ASHA facilitator will interact with ASHA at least twice if not thrice a month. At least one of these interactions will be in the form of a mentoring visit to the hamlet where she provides her services. This would focus on mentoring or on-the-job training. Another one or two interactions would be in a local review meeting. This could be held at Gram Panchayat (GP) level, or at the sector level or even at the block level. Each of the facilitators will have a clear protocol of activities to follow for the mentoring visit to the ASHAs and for the review meetings. The purpose of these interactions are: a b c d e f g Collecting health related information as observed by ASHA and information on what work ASHA is doing. For providing support to the ASHA to manage the health problems they encounter. For providing training and refresh or update their knowledge and skills. For helping ASHAs plan their work. For building up mutual solidarity and motivation. For troubleshooting problems, especially as regards payments and addressing grievances. For refills to their drug kit The Medical Officer In-charge of the block PHC/CHC should a end at least one monthly meeting of all ASHAs in the Primary Health Centre (PHC) area, to review work progress. ASHA Module 6 18 Simple Skills that Save Lives

20 PART B Maternal Health

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22 PART B Maternal Health Objectives of this session By the end of the session the ASHA will learn about: Diagnosing pregnancy using Nischay Kit. Determining Last Menstrual Period (LMP) and Expected Date of Delivery (EDD). Key components of antenatal check-up 1. Identification of problems and danger signs during the antenatal period and appropriate referral. Provide appropriate care for anaemia. Developing plans for birth preparedness. Follow-up with pregnant women. Knowledge of safe delivery. Understand obstetric emergencies and enable appropriate referral for emergencies. Updating Maternal Health Cards with support from the ANM. 1. Pregnancy Diagnosis Diagnosis of pregnancy should be done as early as possible a er the first missed period. There are two ways to diagnose pregnancy early: Missed Periods Pregnancy testing: through use of the Nischay home pregnancy test card The Nischay test card can be used easily by you to test if a woman is pregnant. The test can be done immediately a er the missed period. A positive test means that the woman is pregnant. The benefit of early diagnosis of pregnancy is that the woman can be registered early by the ANM and start ge ing antenatal care soon. A negative test means that the woman is not pregnant. In case she is not pregnant and does not want to get pregnant, you should counsel her to adopt a family planning method. Instructions for the use of the Nishcay Kit are in Annexe 2. 1 All knowledge areas in this chapter have been covered in ASHA Module 2. Part B Maternal Health 21

23 Determining LMP and EDD When pregnancy is diagnosed, you should help the pregnant woman in calculating the probable date when she is likely to deliver. Steps to find the EDD Find out from the woman the date of the first day of her LMP. Then count nine months a er that date. Add seven days to that date. For example, If the first day of the LMP is: 10th Dec Nine months later is: 10th Sept Adding seven days is: 17th Sept Therefore, the expected date of delivery is 17th September 2010 Note: This method only gives an approximate date of delivery, and baby may be born anytime during 15 days before or after the EDD. The Circle Aid for Determining Last Menstrual Period (LMP) and Expected Date of Delivery (EDD) This picture drawn beside helps you in estimating the date of delivery The Measuring Strip to Determine Change in Year January February March April May June July August September October November December January February March April May June July August September October November December ASHA Module 6 22 Simple Skills that Save Lives

24 Facts about Antenatal Check-up How many antenatal check-ups? Four antenatal visits must be ensured, including registration within the first three month period. The suggested schedule is as below: 1st visit: Within 12 weeks preferably as soon as pregnancy is suspected for registration of pregnancy and first antenatal check-up 2nd visit: Between 14 and 26 weeks 3rd visit: Between 28 and 34 weeks 4th visit: After 36 weeks It is advisable for the pregnant woman to visit the Medical Officer (MO) at the PHC for the third antenatal visit, as well as availing of the required investigations at the PHC. Essential components 2 of antenatal care Early registration Regular weight check Blood test for anaemia Urine test for protein and sugar Measure blood pressure One tablet of IFA every day for three months to prevent anaemia Treatment for anaemia Two doses of Tetanus Toxoid (TT) vaccine Nutrition counselling Preparing for birth. 2 The components of ANC have already been covered in Module 2. Part B Maternal Health 23

25 Where are ANC services provided? The nearest place for ANC services for a woman is at the AWC during the monthly VHND. The pregnant woman could also go to the Sub-Centre, where the ANM will provide ANC services. ANC services are also provided at the PHC or Community Health Centre (CHC) or district hospital. Identification of problems and danger signs Given below are complications that can occur during the antenatal period for which pregnant women must seek treatment in an institution: Jaundice, high blood pressure, fever with chills, or bleeding Severe anaemia Women with protein and sugar in their urine Swelling of feet, face and hands. Given below are danger signs for which pregnant women must seek delivery in a centre where they can manage complications including those requiring surgery and blood transfusion. Mothers who had a complication in a previous pregnancy (C section, prolonged labour, stillborn, neonatal death) Pregnant women with severe anaemia. Pregnant women having any of the danger signs of the antenatal period which are still persisting at the time of delivery. Some women are to be considered more at risk of developing complications during delivery and therefore, must opt for an institutional delivery. These include: Young mothers (below 19 years of age) Mothers who are over 40 years of age Mothers who already have three children Mothers who have excessive weight gain or do not gain enough weight. Key tasks to be undertaken during ANC List all pregnant women: Ensure that you cover the women in the poorest families, and in any sections which tend to get le out, e.g. women from SC/ST communities, women living in hamlets far from the main village, or in hamlets that fall between villages and newly migrant women. Educate pregnant women about care in pregnancy, especially on the importance of increased nutrition, rest, and complete ANC services. ASHA Module 6 24 Simple Skills that Save Lives

26 Emphasise the importance of a balanced and nutritious diet during pregnancy. The diet of the pregnant woman should contain a mix of cereals, pulses (including beans and nuts), vegetables including greens, milk, eggs, meat and fish. If possible, the family should be encouraged to add oils, jaggery and fruits to the diet. Meat and nuts are especially good for anaemic women. You should explain to the mother and family that no foods should be forbidden during pregnancy. See when ANC is due for each check-up and remind them appropriately. Escort pregnant woman to VHND where they are hesitant or need such support. Ensure that all components of ANC are delivered. Ensure that the Maternal Card is updated. Planning for Save Delivery You should Know how to calculate the EDD and communicate this to the pregnant woman. Know which institutions in the area provide different levels of care and establish linkages with providers there. At least once before delivery, take the pregnant woman to this centre and introduce her to the providers. Know what transport is available _ whether funded by the state or other private means _ that is easily accessible and affordable and how to call on it when the need arises. Assist all pregnant women and families to prepare plans for birth: including identifying funding sources should money be required at short notice. Sometimes Self-Help Groups (SHGs) may advance money in emergency even if the woman is not a member. This is most important for women in remote hamlets, or in communities which are currently not availing of institutional delivery or those at high risk for complications. Know what records (BPL card) need to be carried to the institution. Share birth plans with ANM and PHC MO at the VHND or monthly meeting. Identify mothers with complications, or a high likelihood of developing complications with support from the ANM. Inform them of the institutions that it is most advisable for them to go to and motivate the mother and the family to go there and escort them if required. Part B Maternal Health 25

27 2. Birth Preparedness for a Safe Delivery What is Birth Preparedness? This is a method of planning in advance by the pregnant mother and her family for a safe and comfortable delivery and for care a er delivery. You should help every family make this plan in consultation with the ANM. What are the choices available to the mother? 1. If there are any danger signs or complications: Identify the nearest institution (CHC/District Hospital) which has the staff and equipment to provide Comprehensive Emergency Obstetric and Newborn Care (CEmONC), and counsel the mother and the family to go there. 2. If there are no complications: Counsel the mother to go to the PHC which is open 24 X 7, where there is a team of doctors and nurses or ANMs to conduct the delivery and provide care for the mother and newborn. These institutions can manage some complications and transfer immediately to a higher facility if complications requiring surgery or blood transfusion develop. The list of such institutions can be obtained from the ANM. The place should be clean and safe and friendly and have a skilled nurse or doctor at all times. The woman would have to stay there for 48 hours a er delivery. 3. If there are no complications and mother and her family are reluctant or unable to go to the 24x7 PHC or if it is too far away: Advise the mother could go the Sub-Centre, provided it is accredited as a delivery centre, which means the ANM has been trained as a Skilled Birth A endant (SBA), and is available, and there are minimum facilities for delivery. 4. If there are no complications or not a high risk case for developing complications and the mother and family insist on delivering at home, despite counselling: You could work with the ANM to enable a delivery by SBA. This should be agreed to only if you are sure that the family can organise transport and funds at very short notice. The SBA should be able to arrive within 30 minutes of the onset of labour at the home/sub-centre and should able to stay through the process of labour and for a few hours a erwards. A team of two or three women with experience in a ending at labour would be helpful. What does a birth preparedness plan contain? (See Annexe-3 for format for individual plan) When should a birth preparedness plan be readied? ASHA Module 6 26 Simple Skills that Save Lives It should be ready as early as possible a er confirming the pregnancy, and in consultation with the family (husband, mother-in-law, or other decision makers). You should review the plan in the third trimester (a er seventh month) with the family and the ANM. At this time, the choice of institution and the transport should be finalised.

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