Knowledge and Practice of Accredited Social Health Activists for providing Maternal and Child Health care in Murshidabad district of West Bengal

 

Pasi A R¹, Dan Amitabha^1, Kunal Kanti De², Roy Bibhash³, Jalaluddeen M¹

¹Airport Health Organisation, Ministry of Health & Family Welfare, Govt. of India, Sahar   Approach Road, Andheri (E), Mumbai – 400099

²Deputy CMOH, Howrah, West Bengal Public Health & Administrative Services

³Deputy Assistant Director of Health Services, West Bengal Public Health & Administrative Services

*Corresponding Author E-mail:

ABSTRACT:

Background: In India ASHA programme was launched in 2006 to facilitate the delivery of mother and child health services in rural areas. We conducted a study in Murshidabad district of West Bengal to describe the knowledge and functioning of ASHAs in relation to maternal and child health care services. Methods: We interviewed 237 ASHAs working in Murshidabad district to collect information about the socio demographic details, job profiles, training, knowledge and functions and the challenges faced by them during working. Results: Most of the ASHAs conformed to the standard selection criteria in terms of age, marital status and education. One third ASHAs were Muslims in that district where two third of the population belonged to the same religious community. One third of them were not residents of their areas. Knowledge of ASHAs about breast feeding practices, low birth weight was below the expected. Conclusion: Vacant posts of ASHAs are to be filled up and their selection should be representative of the community they serve. It is to be ensured that their job profiles correspond to the national guidelines. Training to be arranged regularly to update their knowledge levels on home based maternal and neonatal care. They need encouragement for more home visits.

 

 

INTRODUCTION:                              

In India the maternal mortality ratio (MMR) during 2006-10 was 250 per lakh live birth ^1-4. Presuming the decline being log linear, the MMR would be around 231 per 100,000 live births by 2012⁵. The infant mortality rate (IMR) in India is 48 per 1000 live births and neonatal mortality rate (NMR) is 32 per 1000 live births^5,6. The annualized reduction rate of under 5 mortality in India since 2001 is only 3 percent⁵. Moreover the rate of decline of IMR has practically stopped since last 5 years because NMR is remaining stagnant due to gap between the health service delivery system and its utilization. This gap is mainly due to not reaching the health benefits to the targeted underserved population⁷. There have been efforts to bridge the gaps through community health workers (CHW) in many parts of the world. CHWs are the basic health workers and serve the community where they live⁸.   In India there was a cadre of Community Health Guides (CHG) formed as a 100% centrally funded scheme in 1978 as per the recommendations of the Srivastava Committee/ Fifth Five Year Plan. However, this scheme failed due to lack of community support and was discontinued in 2002⁹. In 2002, Mitanin programme was started in Chhattisgarh¹⁰. The Mitanins were women health workers whose role was defined as a mix of community level care provision, facilitators and activists. This programme was the precursor of the Accredited Social Health Activists (ASHA) programme started in 2006 under the National Rural Health Mission (NRHM). The NRHM was launched in 2005 with an objective to provide effective health care to the rural population^{11, 12}.

ASHAs are the link agents between the community and the health care delivery system. They are trained to facilitate delivery of basic and primary health care including mother and child health services to the village doorsteps. As per NRHM guidelines, every village / large habitat of 1000 population should have an ASHA chosen by and accountable to the Panchayat¹¹. ASHA must be primarily a woman resident of the village and she must be married/widow/divorced/ separated and preferably in the age group of 25-45 years. She should be a literate woman with formal education of up to 8th class with communication and leadership qualities^{11 - 13}. She must be trained in five to seven modules for ASHA and has to do her job about 3-4 hours per day for which she gets performance based incentives on monthly basis.

It was hoped that with post natal home visits by ASHAs the NMR and thus IMR would decrease and mother and child health would improve to a considerable level as shown by Gujarat and Gadchhiroli models in this country¹⁴. But that was not achieved in the country. There came a need to assess and evaluate the functioning of the ASHA programme. Up till now there has only one evaluation of the ASHA Programme been conducted by the National Health System Resources Centre, New Delhi¹⁵.

 

In West Bengal the IMR is 33per 1000 live births and NMR is 26 per 1000 live births¹⁶.The state also has the same stagnant NMR and IMR since last five years¹⁷.  Murshidabad district of West Bengal is socio-economically backward. ASHA programme has been running in Murshidabad since early 2009. There are currently 4270 ASHAs working in the district as against the sanctioned strength of 5700. We conducted a study in Murshidabad district to describe the knowledge and functioning of ASHAs in relation to maternal and child health care services.

OBJECTIVES:

Present study was conducted with following objectives,

1.      To study the socio-demographic profile of ASHAs working in Murshidabad district of West Bengal

2.      To study the knowledge of ASHAs regarding Maternal and Child Care.

3.      To study the practices of ASHAs at village level for providing Maternal and Child Care. 

 

MATERIAL AND METHODS:

Study area:

Murshidabad had a total population of 7,102,430 as per 2011 census. Twenty percent of the population in the district were females of child bearing age (15-45 years) and 21% population were children of 0-6 years.

 

Study population:

ASHAs who had worked in the district for at least one year were included in the study population.

 

Study design:

A cross sectional study was conducted among ASHAs in Murshidabad district of West Bengal.

 

Sampling and Sample size:

There were total 4270 ASHAs working in Murshidabad district. Calculated sample size was 237. The sample size was calculated within 95% confidence interval, absolute precision of 5%, non response rate of 10% and post natal visit by ASHAs up to 82% as reported by National Health Systems Resource Centre (NHSRC) study¹⁵.

 

A line list of all ASHAs working in Murshidabad district of West Bengal was created. From the line list of 4270 ASHAs, a sample of 237 ASHAs was selected by using systematic random sampling.

 

Data collection: Data collection was done by interviewing the ASHAs. Interview was conducted by using a pre-tested questionnaire developed by the National Health Systems Resource Centre, New Delhi¹⁷. The data collection instrument was translated in local Bengali language. Data was collected on socio-demographic characteristics, training, knowledge and practices about the ten functions in relation to mother and child health services performed by them in the last six months. Data collection was done by trained field workers and supervisors. Study was conducted from January to March 2012.

 

Data Analysis:

Data analysis was done by using Epi-Info (3.5.1 version, CDC Atlanta, USA). Data was summarised by using Mean, Median and Proportions as statistical tool.

 

 

Human subject protection:

The respondents provided written informed consent in local Bengali Language. The study was approved by the ethics committee of the National Institute of Epidemiology (ICMR), Chennai.

 

RESULTS:

Out of total 4270 ASHAs working in Murshidabad district 237 (5.6%) were interviewed. Out of 237 ASHAs interviewed, 62% were above 35 years of age (age range 28 – 44 years), 96% were currently married and 63% were educated up to secondary school level.  Nearly two third of them were permanent resident of the villages where they were working and 60 % of them were homemaker. About one third of them were of Muslim religion and 41% were belonged to scheduled caste and scheduled tribe categories. Most of them (83%) had up to 2 children. Median monthly family income was 4000 rupees (range 800 – 30,000 rupees) and 22% of them belonged to BPL families (Table 1).

 

Table 1: Socio-demographic characteristics of ASHAs working in Murshidabad district of West Bengal - India (N= 237)

 

Particulars	Characteristics	Number	Percentage
Age	<35 years	90	37.97
	≥35 years	147	62.03
Marital status	Married	228	96.2
	Widow, divorced and separated	9	3.8
Educational level	Up to secondary pass	150	63.3
	≥Higher secondary	87	36.7
Occupation	Homemaker	142	59.9
	Self employed and others	95	40.1
Religion	Hindu	169	71.3
	Muslim	68	28.7
Caste	General and OBC	141	59.5
	SC, ST	96	40.5
No. of children	Up to 2	196	82.7
	More than 2	41	17.3
BPL card holder	Yes	53	22.4
Resident of service area	Yes	161	67.9
Monthly Family Income    Median ±SD (Range)	Rs 4000 ± 800 (500 – 30000)

 

 

KNOWLEDGE:

Antenatal and Postnatal Care: Regarding advice to a pregnant woman with toxaemic complications, 64% of the ASHAs mentioned that they would immediately refer such mothers to PHC/FRU while 33% ASHAs mentioned that they would refer them to sub-centres. Only 10% (n=24) and 11% (n=26) of them mentioned that they would ensure regular antenatal check up and motivate for institutional delivery respectively. Most of the ASHAs knew that 2 doses of tetanus toxoid vaccines are necessary for primigravida. 84% (n=198) and 44% (n=104) of the ASHAs knew excessive bleeding and foul smelling discharge are important danger signs after delivery respectively.

 

Newborn care and care during childhood illnesses: Most of the ASHAs (n=209, 88%) counsel mothers for colostrums feeding. 82% (n=194) of the ASHAs said that they advised for keeping the baby warm. Over 95% ASHA had correct knowledge of time of initiation and duration of breast feeding but 72% of the ASHAs would counsel mothers for early breastfeeding. Only 59% (n=140) ASHA would advice for exclusive breast feeding. For managing an infant with acute diarrhoea, 76% said that they would give ORS from their drug kits while 27% ASHAs mentioned that they would also advice for continued feeding the infant. Only 42% (n=100) of the ASHAs knew correct method of preparation of ORS. 89% of the ASHAs knew that hand washing as one of the options for preventing diarrhoea in children. 69% (164) of the ASHAs knew that chest in-drawing is an important danger sign of acute severe pneumonia. Over 96% of the ASHAs knew of National Immunization Schedule and which vaccines could be given as per schedule. About 77% of them had expected any bad or adverse effects following immunization (Table 2).

 

Functions of ASHAs: 

All the ASHAs in the district were functional with more than 80% of them mentioning that conducted house to house visits for post natal services and promoted immunization in the past six months.

 

Antenatal care for pregnant women:

Fourth of the ASHAs (n=178) counselled pregnant women on all aspects of pregnancy, 70% (n=166) conducted group sessions with pregnant mothers and children. 56% of the ASHAs (n=132) accompanied pregnant women for delivery. 49% (n=117) of the ASHAs reported that they had identified pregnant women with complications in last six months. Of these, 30% (n=35) ASHAs referred the women to FRU, 47% (n=55) ASHAs referred them to ANM and 7% (n=8) referred the women but the women did not go. The rest of the 16% (n=19) ASHAs escorted the pregnant women to the health facilities for delivery.

 

Postnatal care for pregnant women:

88% (n=208) of them reported that they had visited house to house for post natal services which was the commonest job performed by the ASHAs in the last six months.

 

Newborn care and care during childhood illnesses: Promoting immunization was the second most common function performed by the ASHAs (83% n=196) Visiting newborns for advice and care was done by 77.6% ASHAs (n=184). About 61% (n=145) of them consulted mothers for childhood illness and 56% of the ASHAs (n=111) provided drugs to sick children from her drug kit. Of the ASHAs 44% (n=104) conducted sessions with mothers and small children on malaria and tuberculosis. Half of the ASHAs (n=118, 50%) conducted VHSC meetings (Table 3).

 

Table 2: Knowledge of ASHAs regarding maternal and child care in Murshidabad district of West Bengal (n=237)

Particular	Characteristic	Number	Percentage
Regarding  management  of  a pregnant woman with toxaemic complications	Refer to PHC/FRU	152	64.1
	Refer to sub centre	78	32.9
	Notify ANM	55	23.2
	Motivate institutional delivery	26	11
	Ensure regular ANC	24	10.1
The  important  danger  sign after delivery she looked for	Excessive bleeding	198	83.5
	Foul smelling discharge	104	43.9
	Problem in initiation of breast feeding	104	43.9
	Low birth weight of new born baby	69	29.1
ASHAs’advice to a mother for new born care	Counsel for colostrum feeding	209	88.2
	Keep the baby warm	194	81.9
	Breast feeding within ½ hour	172	72.6
	Advice on immunization	165	69.6
	Exclusive breast feeding for 6 months	140	59.1
	Weighing the child	129	54.4
	Delay bathing the newborn	121	51.1
	Advice for birth registration	91	38.5
No. of tetanus toxoid given to pregnant woman	2	225	94.9
	More than 2	12	5.1
What newborn baby should be given	Nothing except breast milk	229	96.6
	Others	8	3.4
When breast feeding should be started	Within ½ hour after birth	227	95.8
	Others	10	4.2
Duration of exclusive breast feeding	6 months	230	97.1
	Others	7	2.9
Advice of ASHA to a mother of child with infantile diarrhoea	Give ORS from drug kit	181	76.4
	Immediate refer to PHC	142	59.9
	Continue feeding to child	65	27.4
	Give HAF	61	25.7
Know ORS preparation	Correct	100	42.5
What ASHA would look for in a 3-year old child with acute respiratory infection	Chest in drawing	164	69.2
	Difficulty in breathing	102	43
	High fever and running nose	111	46.8
Knowledge of ASHA regarding  options to prevent infantile diarrhoea	Promotion of hand washing	211	89.0
	Keep surrounding clean	184	77.6
	Bathing child daily	77	32.5
Why vaccines are given	To prevent diseases	217	91.6
	Other responses	20	8.4
Knows Immunization Schedule	Yes	233	98.3
The vaccines which are given under 1 year of age	All as per NIS	226	95.8
	Other responses	11	4.2
Expect any bad effect following immunization	Yes	54	22.8
	No	183	77.2

Responses to questions were multiple

 

Table 3: Practices of ASHAs regarding maternal and child care in Murshidabad district of West Bengal (n=237)

Characteristic	Number	Percentage
House to house visits for post natal services	208	87.8
Promoting immunization	196	82.7
Visiting newborns for advices/care	184	77.6
Counselling women on all aspects of pregnancy	178	75.1
Conducting group sessions with pregnant women / small babies	166	70.0
Consultation for childhood illness	145	61.2
Accompanying for delivery	132	55.7
Conducting VHSC meetings	118	49.8
Provision from drug kit to child	111	46.8
Malaria/TB sessions	104	43.9
Carries drug kit on the day of survey	161	68.2
ASHAs identifying high risk pregnant women in last 6 months	117	49.4
ASHAs managed women by referring to ANM	55	47.4
ASHAs managed women by referring to FRUs	35	29.5
ASHAs managed women by escorting to PHC / FRU	19	16.4

 

 

 

DISCUSSION:

In Murshidabad, most of the ASHAs conformed to the standard selection criteria in terms of age, marital status and education^{15, 17}. However, about one third of them were not residents of areas they served. Most of them served more than 1000 population. Their knowledge about the new born and child health care was inadequate. House to house visits for post partum check up and promotion of immunization were the most common functions conducted by the ASHAs.

 

In Murshidabad, about 64% of the population is constituted by Muslim. However, only one third of the ASHAs in the district belonged to Muslim religion. This might be an important reason of facing difficulty in visiting houses as slightly more than one third of the ASHAs reported. The ASHAs have to be resident in their service area for their easy availability in the community as it is one of the basic principles of selection of any community health worker. But in Murshidabad one third of them were non-residents of the village where they were working.

 

A per the NHSRC evaluation, almost all ASHAs in two districts of West Bengal counselled pregnant women about antenatal care visits and more than 90% of them accompanied women for delivery. In Murshidabad, while majority of the ASHAs conducted house to house visits for post natal services and promoting immunization, about half of them did not accompany the pregnant women for delivery and about one fourth of them did not counsel the pregnant women on all aspects of pregnancy like maintaining nutrition and cleanliness and personal hygiene during antenatal period, early identification of danger signs, completing tetanus toxoid vaccination, counselling on institutional delivery and arrangement for post natal care.

Half of the ASHAs identified pregnant women with various pregnancy related complications.

Among those ASHAs who identified such women with pregnancy related complications, less than one fifth of them accompanied the women to health facilities for institutional delivery and about half of the ASHAs referred the women to ANMs as ASHAs get maximum support from the ANMs¹⁸.

 

CONCLUSIONS:

It became apparent from the findings of this study that there was deficiency in knowledge and functions of ASHAs on a few key issues of maternal health and neonatal survival like breast feeding, low birth weight, keeping baby warm and post natal home visits..

 

RECOMMENDATIONS:

1.      More ASHAs are to be trained in modules 6 and 7. For that more refresher training rounds in those modules are necessary so that their knowledge and skill in home based mother and child health care remain sustained and updated.

2.      ASHAs should be encouraged to do post natal home visits for advices to new born babies. They also should accompany pregnant mothers for delivery in health facilities in more numbers especially if the pregnant mother is having complications. This would help in promoting institutional delivery.

 

REFERENCES:

1.       World Health Organization. Maternal Mortality Fact sheet No. 348. Geneva: World Health Organization; May 2012.

2.       World Health Organization. World Health Statistics 2012. Geneva: World Health Organization; 2012.

3.       Kanupriya Chaturvedi SKC. State of infant and maternal mortality in India. . New Delhi; 2011.

4.       United Nations Development Group. Thematic papers on MDG 4, 5 and 6. New York; 2010.

5.       United Nations Children’s` Fund. India Country Fact sheet. New Delhi: United Nations Children’s` Fund; 2012.

6.       Registrar General of India. SRS Bulletin. New Delhi: Registrar General of India, Ministry of Home Affairs, Government of India; 2010.

7.       Dadhich JP PV, editors. State of India's New born. New Delhi: National Neonatology Forum; 2004. p. 13-4.

8.       Wikipedia. Community health Worker. 2012 [cited 20th June, 2012]; Available from: en.wikipedia.org/wiki/Community_health_worker

9.       Kishore J. National Health Programs of India. 10th ed. New Delhi: Century Publications; 2012.

10.     Mitanin Programme in Chhattisgarh- India's Largest Community Health Volunteer Programme. 2004 [cited 2012 10 June]; Available from: http://health.cg.gov.in/.../Mitanin%20Programme%20draft...pdf

11.     Mission NRH. Mission document 2007-1`2. New Delhi: Ministry of Health and Family Welfare.

12.     Dhingra MK. NRHM - Merits and Challenges. 2011 [cited 2012 12 Jun]; Available from: Available from www.assocham.org/events/recent/event_290/Manoj_dhingra.ppt

13.     National Rural Health Mission. Guidelines on Accredited Social Health Activists (ASHA). New Delhi: National Rural Health Mission; 2006.

14.     World Health Organization UNCF. WHO - UNICEF Joint Statement_ Home visits for the new born child: a strategy to improve survival 2009 [cited; Available from: http://whqlibdoc.who.int/hq/2009/WHO_FCH_CAH_09.02_eng.pdf

15.     National Rural Health Mission. ASHA which way forward...? New Delhi: National Health Systems Resource Centre; 2011.

16.     Government of West Bengal. Health on the march. Kolkata: State Bureau of Health Intelligence, Directorate of Health Services, Government of West Bengal.; 2009-10.

17.     United Nations Children’s` Fund. The State of the World’s Children. New York: UNICEF; 2009.

18.     National Rural Health Mission. Guidelines on Accredited Social Health Activists. New Delhi: National Rural Health Mission; 2005.

 

Received on 01.02.2016       Modified on 05.03.2016

Accepted on 26.03.2016      © A&V Publication all right reserved