ABSTRACT
Background:
Accredited social health activist (ASHA) workers act as a “bridge” between rural people and health service outlets and play a central role in achieving national health and population policy goals. According to the National Family Health Survey (NFHS) V (2019–2021) data, infant mortality rate (IMR) is still high in rural areas (32.4 per 1000 live births) in Punjab, compared to urban areas (20.1). Maternal mortality ratio (MMR) is also high (129 per lakh), according to sample registration system (SRS) 2016–2018 data.
Materials and Methods:
In this descriptive, cross-sectional study conducted at RHTC, Bhadson, we assessed the knowledge of ASHA workers regarding maternal and child health (MCH) services and their provision by them to their beneficiaries (mothers with children aged 0–6 months). Out of the total 196 ASHA workers, 72 were selected randomly to assess their knowledge, while 100 beneficiary mothers were interviewed face to face to assess the services provided by the ASHA workers.
Results:
Almost 65.2% of ASHA workers were above 35 years of age. Majority of the ASHA workers (40/72) replied that average weight gain in pregnancy is 10 kg. Very few, that is, 17 (23.6%), ASHA workers knew that breastfeeding should be started within the first hour after delivery of the baby. Counseling regarding nutrition, birth preparedness, institutional delivery, and birth registration was given by ASHA workers to 75%–85% of mothers. There was statistically significant improvement in the practices by mothers with the counseling given by ASHA workers regarding pre-lacteal feed, utilization of family planning methods, and delaying early bathing.
Conclusions:
The study concludes that ASHA workers have good knowledge regarding various aspects of antenatal period, but when it comes to postnatal period and care of the newborn, there are some lacunae. These aspects of newborn care need to be reinforced into the refresher trainings of the ASHA workers.
Keywords: ASHA workers, MCH services, rural health training center
Introduction
Sustainable Development Goals aim is to reduce the global maternal mortality ratio to less than 70 per 100,000 live births by 2030 and end preventable deaths of newborns and under-five children by 2030.
Every day, approximately 830 women die from preventable causes related to pregnancy and childbirth globally. Around 99% of all the maternal deaths occur in developing countries. Maternal mortality is higher in women living in rural areas and among poorer communities. Skilled care before, during, and after childbirth can save the lives of women and newborn babies.[1]
Rural population of India, which contributes around 70% of the Indian population and has direct impact on health indicators, does not get quality health services as the best health services are available only in urban areas. In order to fill this vast gap between urban and rural health-care delivery system, National Rural Health Mission (NRHM) was launched on April 12, 2005 by the Government of India. The aim of the NRHM program was to appoint one accredited social health activist (ASHA) per 1000 population in rural areas. These ASHA workers act as a “bridge” between the rural people and the health-care delivery system.[2]
India has around 17% of the world’s population, but it contributes around 19% of maternal deaths and 21% of global childhood deaths.[3,4,5] Maternal mortality ratio was 254 per 1 lakh live births in 2004–2006, which decreased to 113 per 1 lakh live births in 2016–2018.[6]
Maternal mortality ratio (MMR) was 122 per 1 lakh live births in Punjab in 2016.[6] The infant mortality rate (IMR) was 42 per 1000 live births in 2005–2006. In 2019–2021, the IMR in Punjab was 28 per 1000 live births. There is a marked difference topographically also with 20.1 per 1000 live births IMR in the urban areas and 32.4 per 1000 live births in the rural areas of Punjab.[7] We have made improvement in our country since the introduction of NRHM in 2005. The IMR declined from 57 per 1000 live births in 2005–2006 to 32 per 1000 live births in 2018.[8] Maternal mortality rate in Punjab was 178 in 2001–2003 and 192 in 2004–2006, which decreased to 172 in 2007–2009, 155 in 2010–2012, and 141 in 2013–2015 according to the sample registration system.[9]
Data regarding knowledge of ASHA workers and its application in delivery of maternal and child health (MCH) services is not available in this part of country. Hence, this study was planned to locate the gaps, so that the quality of work by ASHA workers can be improved.
Materials and Methods
Study design and duration
A community-based descriptive, observational, cross-sectional study started from January 1, 2018, till the sample collection was completed.
Study area
This study was conducted in Bhadson, a rural field practice area of Department of Community Medicine, Government Medical College, Patiala, which is at a distance of about 30 km from Patiala. Total population of Bhadson block was 2,02,185, and it consisted of 173 villages and 196 ASHA workers.
Target population
ASHA workers
Mothers with children aged 0–6 months
Sample size
Using sample size calculation for finite population with qualitative data, the sample of ASHA workers was calculated by the formula 4PQ/L2 and by applying a correction factor,[9] where the confidence interval was taken as 95% and the allowable error was 10%. By this formula, the sample size came out to be 66; further keeping 10% as the nonresponse rate, the overall sample size calculated was 72. There were 196 ASHA workers in the rural training and health centre (RTHC) Bhadson; so, the sampling frame of ASHA workers was obtained from a senior medical officer (SMO) in charge of Bhadson, and then by using lottery method of simple random sampling technique, 72 ASHA workers were selected from this sampling frame.
According to data obtained from the respective SMO office of Bhadson, 1068 deliveries were escorted by ASHA workers to the public health facility in Bhadson block in year 2016. Using the formula 4PQ/L2 with finite population, allowing 10% nonresponse rate, and assuming 50% utilization rate of services, we calculated 100 beneficiaries (mothers with children aged 0–6 months).
Ethical considerations
Due clearance was obtained from the institutional ethical committee, and permission to conduct the study was taken from the SMO in charge of community health centre (CHC) Bhadson. Written informed consent was obtained from all the participants of the study. Only those participants who gave the written consent were interviewed.
Data collection
In this study, two separate semi-structured and pretested questionnaires were used to collect data. In the first questionnaire, the knowledge of ASHA workers regarding MCH services was assessed. The second one was used to study the maternal and newborn services provided by ASHA workers in recently delivered mothers with children aged 0–6 months. Face-to-face interview was conducted to fill all the questionnaires.
Data analysis
Data thus generated was compiled and analyzed using Epi Info 7 software. The analysis of data was done using both descriptive and inferential statistics. Pearson Chi-square test was used for testing statistical significance of the association of various variables.
Selection criteria
ASHA workers working in the same location for a minimum period of 2 years and recently delivered mothers with children aged 0–6 months of age who have received MCH services at that place were included in the study. ASHA workers not willing to participate in the study and not available during the period of data collection and study, along with those mothers who were not willing or refused to give consent or have recently migrated from some other area were excluded from the study.
Results
In this study, knowledge of 72 ASHA workers was assessed using a pretested semi-structured questionnaire. Maximum number of ASHA workers, that is, 67 (93.05) ASHA workers, belonged to Sikh religion. The sociodemographic profile of ASHA workers is presented in Table 1.
Table 1.
Sociodemographic profile of ASHA workers
| Characteristics | Number (%) |
|---|---|
| Age | |
| 25-29 years | 18 (25) |
| 30-34 years | 7 (9.7) |
| 35-39 years | 27 (37.5) |
| 40-45 years | 20 (27.7) |
| Population covered | |
| 800-999 | 20 (27.7) |
| 1000-1199 | 25 (34.7) |
| 1200-1299 | 15 (20.8) |
| >1300 | 12 (16.6) |
| Education | |
| Middle | 9 (12.5) |
| Matriculate | 41 (56.9) |
| Senior secondary | 19 (26) |
| Graduate | 3 (4.1) |
| Socioeconomic status (BG Prasad Scale 2017) | |
| >6254, Upper | 3 (4.6) |
| 3127-6253, Upper middle | 16 (22) |
| 1876-3126, Middle | 28 (38) |
| 938-1875, Lower middle | 18 (25) |
| <938, Lower | 7 (9.7) |
ASHA=accredited social health activist
Around 60 (83.33%) ASHA workers knew that pregnancy can be confirmed by Nishchay Kit and 51 (70.83%) ASHA workers replied that missed period and morning sickness can be the methods of pregnancy confirmation. Almost half, 40 (55.55%), of the ASHA workers were aware that average weight gain during pregnancy is around 10 kg. Almost 41.66% (30) knew that iron folic acid (IFA) tablets should be taken for a period of 6 months before and 6 months after delivery.
The knowledge of ASHA workers regarding anemia in pregnancy, postpartum duration, number of postnatal visits to be done in case of Institutional deliveries, and complications in pregnancy and their knowledge regarding child health, such as categorization of weight in a newborn child, initiation of breastfeeding in a cesarean section delivery, timing of giving first bath to the child, and so on is presented in Table 2.
Table 2.
Knowledge of ASHA workers regarding mother and child health
| Knowledge of ASHA workers regarding mother’s health | |
|---|---|
|
| |
| Number (%) | |
| Knowledge of ASHAs regarding the cut-off level of Hb for diagnosis of anemia in pregnancy | |
| <12 g/dl | 5 (6.94) |
| <11 g/dl | 2 (2.77) |
| <10 g/dl | 7 (9.72) |
| <9 g/dl | 58 (80.55) |
| Knowledge of ASHAs regarding duration of postpartum period | |
| Up to 4 weeks | 31 (43.05) |
| Up to 6 weeks | 27 (37.5) |
| Up to 8 weeks | 10 (13.88) |
| Up to 10 weeks | 4 (5.55) |
| Knowledge of ASHAs regarding the number of postnatal visits in institutional deliveries | |
| 5 | 13 (18.05) |
| 6 | 11 (15.27) |
| 7 | 43 (59.72) |
| 9 | 5 (6.94) |
| Knowledge of ASHAs regarding complications in pregnancy | |
| Excessive bleeding | 17 (23.61) |
| Puerperal sepsis | 16 (22.22) |
| Convulsions with or without swelling | 2 (2.77) |
| Perineal swelling | 12 (16.66) |
| All of the above | 46 (63.88) |
|
| |
| Knowledge of ASHA workers regarding child health | |
|
| |
| Initiation of breastfeeding in cesarean section | |
| Within the first hour | 17 (23.6) |
| Within 2 h | 39 (54.2) |
| Within 3 h | 12 (16.7) |
| Within 4 h | 4 (5.6) |
| Low-birth weight babies | |
| 3 kg | 1 (1.38) |
| 2.5 kg | 2 (2.77) |
| 2 kg | 56 (77.77) |
| 1.5 kg | 13 (18.05) |
| Timing of newborn babies’ first bath | |
| After the second day | 37 (51.38) |
| After the third day | 12 (16.66) |
| After the fourth day | 17 (23.61) |
| After the seventh day | 6 (8.33) |
| Fever (temperature in a newborn baby) | |
| 97°F | 20 (27.77) |
| 98°F | 9 (12.5) |
| 99°F | 37 (51.38) |
| 100°F | 6 (8.33) |
| Frequency of weight recording of children | |
| Every week | 14 (19.4) |
| Every alternate week | 9 (12.5) |
| Every month | 46 (63.9) |
| Every alternate month | 3 (4.2) |
ASHA=accredited social health activist, Hb=hemoglobin
The knowledge of ASHA workers regarding complementary feed in a child was assessed. Majority of ASHA workers, 48 (62.66%), were of the view that during illness, complementary feed should be continued; extra feed must be given after the illness and food must not be diluted unnecessarily. About half, that is, 37 (51.38%), of the ASHA workers said that food must be given for 4–6 times per day and oils and fats should be added to the food. Very few, that is, 27 (37.5%), ASHA workers thought that milk, eggs, meat, and fish can be given as complementary feed to the child.
Maternal and newborn services provided by ASHA workers for 100 recently delivered mothers with children aged 0–6 months were also assessed in this study. The sociodemographic profile of mothers is presented in Table 3.
Table 3.
Sociodemographic profile of mothers
| Characteristics | Number |
|---|---|
| Age groups | |
| 19-22 years | 19 |
| 23-26 years | 48 |
| 27-30 years | 31 |
| 31-34 years | 1 |
| 35-38 years | 1 |
| Education | |
| Illiterate | 12 |
| Primary | 6 |
| Middle | 23 |
| Matriculate | 25 |
| Senior secondary | 17 |
| Graduate | 17 |
| Socioeconomic status (BG Prasad Scale 2017), Class | |
| >6254, Upper | 9 |
| 3127-6253, Upper middle | 28 |
| 1876-3126, Middle | 43 |
| 938-1875, Lower middle | 17 |
| <938, Lower | 3 |
It was observed that maximum (n = 80) mothers were registered in the first trimester of pregnancy; 15 got registered themselves in the second trimester, while four were registered in their third trimester. Regular weight recording of only 74 mothers was done, whereas for 26 mothers, it was not done regularly. Only 67 mothers took folic acid and 95 mothers took iron folic acid tablets during pregnancy. Almost all mothers (>95) received all the antenatal services (such as antenatal registration, weight check, blood pressure [BP] check, urine and blood examination, IFA tablets, tetanus toxoid [TT] injections, and abdominal checkups) during the antenatal period with the help of ASHA workers.
Discussion
In this study, the knowledge of 72 ASHA workers regarding MCH services provided in their area and utilization of MCH services among their beneficiaries was assessed. MCH care is one of the important tasks of ASHA, so we have also assessed MCH services provided by ASHA in 100 mothers with children aged 0–6 months.
Sociodemographic profile of ASHA workers
Our study revealed that a majority (37.5%) of ASHA workers were in the age group of 35–39 years, similar to the findings of a study done by Kohli et al.[3] The findings were not in coherence with the study of Sugandha and Jagannath,[10] where the majority belonged to the age group of 25–34 years. Most of the ASHAs (34.7%) covered a population of 1000–1199, similar to the study finding of Shet et al.[11] and contrary to the findings of Sugandha and Jagannath[10] and Pal et al.[12] As per the present study, majority of ASHAs (56.9%) were matriculate pass, similar to the study findings of Pal et al.[12] and Azarudeen et al.[13] and contrary to the study finding of Rohith and Angadi.[14] Most of the (38%) ASHA workers belonged to middle class, which is not similar to the findings of a study conducted by Karir et al.[15] The difference in socioeconomic status may be due to the different study areas and geography.
Knowledge of ASHA workers regarding antenatal care
The present study found that 83.3% ASHAs knew that pregnancy confirmation can be done by using Nishchay Kit, which was similar to the findings of Satish et al.[16] and Pal et al.[12] The findings are not in concordance with the findings of Goel et al.,[17] where only 15.6% of auxiliary nurse and midwife (ANMs) and ASHA workers were aware about the Nischay scheme. In the present study, maximum (55.5%) ASHA workers were of the view that average weight gain in pregnancy should be around 10 kg and 41.66% of ASHA workers knew that IFA tablets should be given 6 months before and 6 months after delivery, contrary to the findings of Sugandha and Jagannath.[10] The knowledge regarding intake of IFA tablets was in concordance with Pal et al.[12] This difference in knowledge may be due to lack of refresher training or the quality of training imparted to the ASHA workers.
As shown in Table 2, regarding the knowledge of ASHA workers related to hemoglobin (Hb) levels for labeling anemia during pregnancy, only 2.77% had correct knowledge, similar to the findings of Azarudeen et al.,[13] where only 10% had correct knowledge.
It was observed that 59.72% of ASHA workers responded that there are seven postnatal home visits, similar to the findings of Kori et al.[18] and contrary to the findings of Sugandha and Jagannath [Figure 1].[10]
Figure 1.
Seven postnatal home visits were done by ASHA workers in only 18 postnatal mothers and six postnatal home visits were done in only 10 mothers
Knowledge of ASHA regarding childcare
In our study, 23.6% of ASHAs knew that breastfeeding should be started within the first hour after delivery of the baby, which is way lower than the findings of Sugandha and Jagannath,[10] Kori et al.,[18] and Azarudeen et al.[13] In the present study, very low percentage of (2.77%) ASHA workers knew that baby with weight less than 2.5 kg is a low-birth weight (LBW) baby, which is lower compared to the results reported by Sugandha and Jagannath.[10] Majority of (51.38%) ASHA workers were of the view that first bath can be given on the second day of delivery, which was in concordance with the findings of Saxena et al.[19] and contrary to the findings of Sugandha and Jagannath[10] and Fathima et al.[5] Maximum (51.38%) ASHA workers were of the view that temperature above 99°F is considered fever in a child, which is correct as per the training module number 6 of ASHA workers.[20] In studies conducted by Grover et al.[21] and Rajawat et al.,[22] it was found that fever was assessed correctly in nearly 73% and 67% of babies, respectively Table 4.
Table 4.
Shows how many out of 100 mothers were counseled by ASHA workers regarding various aspects of care in the antenatal period, newborn care, breastfeeding, place of delivery, and so on
| Number of mothers counseled | |
|---|---|
| Regarding care in the antenatal period | |
| Nutrition | 76 |
| Anemia during pregnancy | 55 |
| Danger signs in pregnancy | 29 |
| Emergency transport | 37 |
| Birth preparedness | 77 |
| Institutional delivery | 85 |
| Birth registration | 81 |
| Family planning | 46 |
| Newborn care counseling | |
| No early bathing | 46 |
| Exclusive breastfeeding | 79 |
| Keeping the baby warm | 77 |
| Skin care | 27 |
| Cord care | 22 |
| Eye care | 17 |
| Immunization | 90 |
| Management of fever, diarrhea, pneumonia, and so on | 34 |
| Breastfeeding | |
| No pre-lacteal feed | 40 |
| Early initiation of breastfeed | 68 |
| Exclusive breastfeeding for 6 months | 76 |
| No water till 6 months | 68 |
| Breastfeeding problems | 22 |
| Place of delivery | |
| PHC | 5 |
| CHC | 64 |
| SDH/DH | 21 |
| Private | 2 |
| Nil | 8 |
ASHA=accredited social health activist
Impact of counseling by ASHA workers on the child practices followed by mothers
In the present study, 46% of mothers were counseled regarding not giving early bath. There was statistically significant improvement in not giving early bath after the counseling of mothers. The results were similar to the findings of Fathima et al.[5] and contrary to the findings of Gul et al.[23]
There was statistically significant improvement in the practices of mothers with counseling given by ASHA workers regarding pre-lacteal feed. It has been observed that in the mothers who were counseled that they should not give pre-lacteal feed to their baby, the practice of giving pre-lacteal feed was not found. The findings were in coherence with the studies conducted by Wadde et al.[24] and were not similar to the study findings of Jayarama and Ramaiah.[25]
There was statistically significant improvement in the practices of exclusive breastfeeding with the counseling done by ASHA workers. Our results were in concordance with the results of a hospital-based study conducted by Tiwari et al.[26] In the present study, counseling of mothers was done by ASHA workers on various aspects related to antenatal period, newborn care, breastfeeding, and place of delivery, as presented in Table 5. The findings of the present study were similar to the findings of a study conducted in Delhi by Ghosh-Jerath et al.,[27] whereas they were not similar to the findings of a study conducted in the Chandigarh Tricity by Dhiman et al.[28] In our study, ASHAs counseled 92% of mothers regarding the place of delivery, which was similar to the findings of Fathima et al.[14] and Nandan et al.[29] i.e 60% and 70% of women respectively conducted, it was as a result of motivation by ASHA. As per the study conducted by Baba et al.[30] in Kashmir, only 5% of the deliveries were conducted at the subcenter, 30.8% at CHC, 17.28% at primary health centre (PHC), and about 3% at home, while 34.7% of the deliveries were conducted at a tertiary care hospital and 8.49% in other places (private nursing homes). This trend may be due to the cultural beliefs prevalent in the area which affect the utilization of maternal services available in the area.
Table 5.
Association between various practices by mothers and counseling done by ASHA workers
| Practices followed by mothers | Counseling done | Significance level | |
|---|---|---|---|
| Practice of early bathing | Yes | No | |
| Yes | 10 (21.7%) | 43 (79.6%) | χ2=33.41, df=1, P<0.001 (HS) |
| No | 36 (78.3%) | 11 (20.4%) | |
| Pre-lacteal feed given | |||
| Yes | 7 (17.5%) | 39 (65%) | χ2=21.8, df=1, P<0.001 (HS) |
| No | 33 (82.5%) | 21 (35%) | |
| Family planning methods used | |||
| Yes | 51 (91.1%) | 2 (4.6%) | χ2=74.05, df=1, P<0.001 (HS) |
| No | 5 (8.9%) | 42 (95.4%) | |
| Exclusive breastfeeding practiced | |||
| Yes | 69 (90.8%) | 14 (58.4%) | χ2=13.617, df=1, P<0.001 (HS) |
| No | 7 (9.2%) | 10 (41.6%) | |
| Early initiation of breastfeeding | |||
| Yes | 14 (20.6%) | 5 (15.7%) | χ2=0.348, df=1, P<0.55 (NS) |
| No | 54 (79.4%) | 27 (84.3%) | |
ASHA=accredited social health activist, df=degree of freedom, HS=highly significant, NS=not significant
As seen in Table 5, for most of the aspects of newborn care, less than 50% of mothers were counseled by ASHAs. Regarding exclusive breastfeeding, keeping the baby warm, and immunization, maximum percentage of mothers (>70%) were counseled. The findings of the present study were similar to the study conducted by Grover et al.,[21] Fathima et al.,[5] and Singh et al.,[31] where most of the mothers were counseled by ASHA workers in relation to breastfeeding and immunization. Present study findings were again similar to the study conducted by Sinha et al.,[32] as per which the counseling given by ASHA workers to mothers with regard to danger signs in newborn and care of eyes of newborn was less.[21] This shows that ASHAs focus on only certain aspects of newborn care, such as breastfeeding and immunization, and areas such as eye care, cord care, management of fever, and so on in the newborn are neglected by most of the ASHA workers in all settings. So, such aspects need to be focused.
Most of the mothers were also counseled by ASHA workers regarding breastfeeding practices; more than 65% were counseled regarding early initiation of breastfeeding, exclusive breastfeeding, and giving no water till 6 months of age. Present study findings were similar to the findings of studies conducted by Grover et al.[21] and Baba et al.[29] and contrary to the findings of Ghosh-Jerath et al.[27] Differences in the study findings may be attributed to the differences in motivation and training of ASHA workers in different study settings.
Conclusions and Recommendations
Conclusion
This study concludes that knowledge of ASHA workers regarding antenatal care was good, except for knowledge regarding anemia during pregnancy, and also, they were using their counseling skills to motivate mothers to utilize antenatal and intranatal services available in the government sector. It has been seen that counseling of mothers by ASHA workers does have an impact on mothers’ knowledge regarding pre-lacteal feed and exclusive breastfeeding. (Change 4)
There was lack of knowledge regarding postnatal care and newborn care, especially regarding birth weight in newborn, which affected their counseling skills also. Due to this, mothers in rural areas suffer a lot as ASHA workers are the only community health workers who can provide them correct and timely help and information.
Need of the hour is to give refresher trainings to ASHA workers regarding mother and childcare, with more focus on postnatal and newborn care. Also, there is a need to monitor the activities of ASHA workers on a routine basis on a large scale, so as to check the quality of services they are providing to their beneficiaries, which can further improve the performance of ASHA workers.
Recommendations
There should be repeated refresher trainings of ASHA workers on topics like postnatal care and newborn care, as the ASHA workers were seen focusing mainly on antenatal and intranatal care. They need to know the importance of postnatal, newborn, and childcare.
There is a direct association of counselings given by ASHA workers to mothers on various aspects of maternal and childcare and the practices of those mothers. So, we need to focus more on improving the counseling skills of ASHA workers. Workshops particularly focusing on maternal and child health can also be held for ASHA workers to improve their counseling and communication skills.
Limitations
The main limitation was that mothers were hesitant in some areas to give information regarding the services provided by ASHA workers, as the ASHA worker was a resident of the same village and the mothers were afraid to explain the actual scenario of services provided by the ASHA workers, even after they were assured of confidentiality.
This study was done only in one rural block of district Patiala, so we cannot generalize the findings.
Despite these limitations, the study provides an important information on the knowledge of ASHA workers regarding mother and child health and the services provided by these ASHA workers to their beneficiaries. This study also contributes to identify various barriers to mother and childcare and guides us the way how we can overcome such barriers.
Declaration of patient consent
The authors certify that they have obtained all appropriate patient consent forms. In the form, the patient(s) has/have given his/her/their consent for his/her/their images and other clinical information to be reported in the journal. The patients understand that their names and initials will not be published and due efforts will be made to conceal their identity, but anonymity cannot be guaranteed.
Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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