Academy of Social Science Journals ISSN: 2456-2394 Home Page: http://innovativejournal.in/index.php/assj/index November, 2019 |Volume 04|Issue11| Pages: 1484-1487

Research Article Knowledge of ASHAS in New Born Care Practices in Relation to Placental Delivery in Uttar Pradesh, India Tridibesh Tripathy Public Health and Homoeopathic Expert, 2/338, Vishwas Khand, Gomti Nagar, Lucknow, UP, India Email: [email protected]

Abstract: When ASHAs were introduced in NRHM in 2005, one of their primary mandates were to track deliveries and visit homes of newborns as the first program and counsel and deliver relevant messages as envisaged under the Comprehensive Child Survival Program (CCSP) way back in 2008 in Uttar Pradesh. Since then, tracking of all the deliveries and the related messages given by ASHAs on newborn care to mothers during pregnancy and in the first month after delivery are an integral part of the work of ASHAs in all the primary health care programs operated by the NHM in UP. The current study explores four of the crucial variables of the knowledge of the ASHAs on newborn care in relation to placental delivery in four districts of UP. The four variables are drying, wrapping, initiating breastfeeding and cord cutting. These cover the thermal care, food and cord care aspects of HBNC. Through this profile, the content and type of newborn care messages given by ASHAs in their coverage area is tracked for assessing their knowledge in relation to placental delivery. The relevance of the study assumes significance as data on the details of activities like the content, timing and quality of messages on newborn care is not assessed with placental delivery. Hence, the knowledge of ASHAs on this aspect is not available in various studies available in the public domain. A total of four districts of Uttar Pradesh were selected using purposive sampling for the study and the data collection was conducted in the selected villages of the respective districts using a pre-tested structured questionnaire with both close-ended and open-ended questions. In addition, in-depth interviews were also conducted amongst the ASHAs and a total 250 respondents had participated in the study. The content of message deliveries by ASHAs in the 4 districts in their catchment area was assessed. Most of the ASHAs in three districts had the correct knowledge of drying the newborn in relation to placental delivery except Gonda district. The ASHAs of Gonda district again had poor knowledge in terms of wrapping the newborn in relation to placental delivery. Regarding knowledge on initiation of breastfeeding and cord cutting, the ASHAs of Barabanki district reflected poorly. This shows that there is an urgent need to reorient ASHAs on the essential birth-planning and newborn care messages in relation to placental delivery especially for home deliveries. This can be done by using the structured mentoring and coaching approach, both, onsite/in-field and facility based by the supportive supervision structure of ASHA Sanginis, ANMs and Medical Officers for better adherence on delivery of the content, timing and quality of messages on newborn care to the prospective mothers and their family members in the community.. Keywords: ASHA, Placenta, CCSP, Sanginis, HBNC, EIBF, Cord care

Introduction th th To address the knowledge issue of the ASHAs, they covered in 6 and 7 module of ASHAs. Till the had a 23 day training schedule in phases while end of 2017, more than half of the total numbers of th th covering the 8 prescribed training modules of GOI ASHAs were trained in 6 and 7 modules out of (NRHM, GOI, 2007). As health was a state subject, the 8 prescribed modules for ASHAs by GOI the training modules were rolled out in phases by the (NHM, PIP, 2017-18, GOUP). As the reinforcement state governments. In the state of UP, the ASHAs and follow up to the training are poor, the were trained in the CCSP module that was knowledge level drips. developed by the state on the lines of the HBNC The knowledge level of ASHAs can only be module of GOI and the module covered the topic of maintained through community support. The essential newborn care. Newborn health was also community support acted as motivation for the ASHAs to practice the knowledge and skills related 1484 Academy of Social Science Journals, vol. 4, Issue 11, November, 2019 Tridibesh Tripathy / Knowledge of ASHAS in New Born Care Practices in Relation to Placental Delivery in Uttar Pradesh, India to HBNC and retained and refreshed the knowledge performance of ASHAs also differs from district to and skills. All these processes helped her to identify district because each district is a separate and refer sick newborns timely while providing need administrative unit and the type of administration based HBNC practices to the mothers and family also affects the role and performance. The current members of the newborns (COP report, Vistaar study incorporates these ground realities while project, 2013). The uneven level of community discussing on the knowledge aspect of ASHAs. support explains the poor performance of ASHAs. Through the contextualization at the district level, A cross sectional community based study of care of the current study describes the phenomena of newborn infants in Nepal stated that health newborn care practices. promotion interventions that were most likely to A delivery has four stages out of which the delivery improve newborn health include improving of the foetus is the first stage and placenta delivery information for families about basic perinatal care, is the third stage as mentioned in the training promoting clean delivery practices, early cord modules of ASHAs (GOI, 2005). The study revolves cutting and wrapping of the baby and avoidance of around the knowledge of ASHAs on newborn care early bathing (David, Kirti. et. al,2002). with the placental delivery as the pivot. The study focuses on knowledge of ASHAs on A study by NHSRC on evaluation of performance of aspects of newborn care in relation to placental ASHAs suggests optimization of ASHA’s delivery. Among the HBNC, warmth component is functionality and effectiveness. It highlights low very critical. A newborn baby is homoeothermic. A performance in areas of newborn care, postnatal low birth weight baby has decreased thermal care, antenatal care and nutrition by ASHAs due to insulation because of reduced amount of brown fat. lack of skills and support (Ved et. al, NHSRC, Newborn loses heat by evaporation (amniotic fluid 2011). The current study also focuses on these areas by surface), conduction (touch with cold object), to see the performance of ASHAs. In other studies, convection (fan, window) where cold air replaces it is cited that evaluations of CHW performance in warm air. The warm and pink feet of the baby 1998, 1999 and 2000 in Siaya, Kenya (Kelly et. al, indicate thermal comfort. The behaviors like delayed 2001) found that key reasons for the deficiencies in bathing, delayed weighing and kangarooing in case performance appear to be guideline complexity and of low birth weight babies contribute to warmth of inadequate clinical supervision. These issues hold the baby (NNFI, 2015). It further summarizes to true for the state of UP also. address three components which were clean airway, Home based newborn care was one of technical breathing and temperature. component of INAP of GOI. The Bottle Neck There were many barriers in HBNC practices like Analysis toll of the global Every Newborn Steering delayed early initiation of breast feeding, non- Group was used to find the package critical to adherence to exclusive breast feeding, poor cord reduce preventable newborn deaths. One of the care and early bathing of newborns. All these factors packages was basic newborn care that covered contributed to higher neonatal mortality (Kumar and cleanliness including cord care, warmth and feeding. Mohanty. et.al, Lancet 2008). These barriers come The other was Kangaroo Mother Care that focuses into play as the ASHAs have poor knowledge. on skin to skin, breast feeding and feeding support for preterm and premature babies (INAP, GOI, Background of ASHAs 2014). This was the HBNC package that the current The ASHAs emerged in India’s public health system study focused upon. during the launch of NRHM in 2005 in the state of The knowledge on EIBF in relation to placental Uttar Pradesh (GOI, 2005). The ASHAs were in fact delivery is also critical as only 25.2% of children in inducted to NRHM with the primary aim to roll out UP are fed the colostrum where as it is 45.2% in the the JSY component of NRHM (GOI, 2005). country (NFHS 4, 2015-16). The current study focuses on knowledge of ASHAs The above studies do not reflect on the knowledge who receive the same inputs from the district level of ASHAs on newborn care in relation to placental as per the guidelines by the state level. The fact is delivery. The current study has the quality and that these inputs differ from district to district as all content for each of the variables on newborn care Vs the factors like the trainers, training environment placental delivery used in the study. This study done and the logistical facilities were different for each of in 2017 examines the profile of the timing and the districts. It is in this light that the current study content of newborn care related messages in the contextualizes the realities at the district level which coverage area of ASHA. usually studies do not cover. The role and 1485 Academy of Social Science Journals, vol. 4, Issue 11, November, 2019 Tridibesh Tripathy / Knowledge of ASHAS in New Born Care Practices in Relation to Placental Delivery in Uttar Pradesh, India Research Methodology these aspects are seen in the context of placental Using purposive sampling technique, four districts delivery. were chosen from the four different economic Table 1 regions of UP, namely Central, Eastern, Western and Percentage of ASHAs who know when to dry the Bundelkhand. Further, the Government of UP in newborn in relation to placental delivery 2009 categorized the districts as per their Names of Banda Barabanki Gonda Saharan development status using a composition of 36 districts pur indicators. Purposefully, the high developed district Immediatel 96.8 96.7 56.2 100 chosen for the study is Saharanpur from the western y after birth region, the medium developed district chosen for the before the study is Barabanki from the central region, the low placenta is developed district chosen for the study is Gonda delivered from the eastern region and the very low developed Within one 3.2 0.0 43.8 0.0 district chosen for the study is Banda from the hour after Bundelkhand region (GOUP, 2009). delivery of placenta In the next step, purposefully two blocks were One or 0.0 0.0 0.0 0.0 selected from each of the district and all the ASHAs more hours in these blocks were chosen as the universe for the after study. From the list of all the ASHAs in each of the delivery of two blocks, 31 ASHAs were chosen randomly from placenta each block for the study. In this way, 62 ASHAs were chosen for the study from each of the districts. This section deals with knowledge of ASHAs In Gonda district, 64 ASHAs were selected to make newborn care in relation to placental delivery. The the total number of ASHAs for the study to 250. first part is on drying the newborn. 56% of ASHAs in Gonda, 97% of ASHAs each in Barabanki and Data analysis Banda, all the ASHAs in Saharanpur replied that The data was analyzed using SPSS software to baby should be dried immediately before the calculate the percentage of ASHAs who had placenta is delivered. 44% of ASHAs in Gonda and knowledge on newborn care. The study deciphered 3% of ASHAs in Barabanki and Banda replied that the home-based newborn care knowledge of ASHAs the baby should be dried within one hour after through the timing of the messages whether before delivery of placenta. This meant that in Gonda, the or after placental delivery. The qualitative data warmth component was poorly managed and done related to the details of the contents of the newborn poorly by ASHAs. care messages given during home visits to newborns Table 2 by ASHAs is possible with the correct knowledge. The knowledge is seen against the prescribed Percentage of ASHAs who know when to wrap the newborn in relation to placental delivery guidelines for ASHAs by GOI regarding the content Names of Banda Baraban Gonda Saharan in the prescribed training modules of ASHAs. districts ki pur Research tool Immediately 100 98.3 92.2 100 after birth The ASHAs were interviewed using an in-depth, Immediately 0.0 0.0 7.8 0.0 open-ended interview schedule which included after birth sections on variables on work done by ASHAs before the through home visits to newborns, escorting placenta is deliveries to institutions, number of home deliveries delivered and number of newborns visited. These activities Within one 0.0 1.7 0.0 0.0 were also seen against their current knowledge on hour after whether a particular activity needs to precede or delivery of succeed placental delivery. placenta One or more 0.0 0.0 0.0 0.0 Results and discussions hours after There are four tables in this section. The first table is delivery of on the knowledge on drying, second on wrapping, placenta third on EIBF and the fourth on cord cutting. All 1486 Academy of Social Science Journals, vol. 4, Issue 11, November, 2019 Tridibesh Tripathy / Knowledge of ASHAS in New Born Care Practices in Relation to Placental Delivery in Uttar Pradesh, India Regarding wrapping, again about 8% of ASHAs in The above results showed that the knowledge on Gonda replied that the baby should be wrapped just cord cutting on newborn care messages was the most before the placental delivery and not immediately. challenging followed by early initiation of breast 2% of ASHAs in Barabanki district replied that baby feeding. These two activities can be done by the should be wrapped within one hour after delivery of community if they are planned and reinforced by placenta. ASHAs. The challenge lies in mentoring-coaching Again, it showed that the ASHAs in Gonda and ASHAs on following up all the deliveries with the Barabanki district had poor knowledge in terms of support of Sanginis (supervisors of ASHAs in UP) managing the warmth component of the newborn. and that too it should be preferably an onsite orientation i.e. during the home visits while Table 3 accompanying the ASHAs. Qualitative analysis of Percentage of ASHAs having knowledge on initiating the messages and effective delivery of these breastfeeding the newborn in relation to placental messages are the two areas that the supervisors need delivery to focus. The training should not be an activity Names of Banda Barabanki Gonda Sahran rather it should be a regular process. All these districts pur parameters should be worked out at the level of Initiate 75.8 43.5 62.5 70.9 ASHAs so that performance is tracked regularly. before placental References delivery Initiate 24.2 56.5 37.5 29.1 1. Bajpai N, Dholakia R. (2011). Improving the after performance of ASHAs in India, working paper placental No.1, working paper series, delivery globalcentres.columbia.edu/southasia, 2011. 2. Report on evaluation of CCSP and ASHA About 30% of ASHAs in Saharanpur, 25% in scheme in UP, Vimarsh, SIFPSA, GOUP, 2013. Banda, 38% in Gonda and 57% in Barabanki replied 3. GOI (2005, 2015). Ministry of Health and that breastfeeding should be initiated after placental Family Welfare; Update on the ASHA delivery. This defeated the purpose of EIBF as all Programme, April 2005, January 2015. the ASHAs across four districts did not have the 4. Government of Uttar Pradesh (2009). Planning complete knowledge of breastfeeding practices. Atlas of Uttar Pradesh; Area Planning Division, Table 4 State Planning Institute, Planning Department. Percentage of ASHAs having knowledge on cord 5. Project Close-Out Report, The VISTAAR cutting of the newborn in relation to placental delivery project, 2006-2012, Intra Health International, Names of Banda Barabanki Gonda Saharan April, 2013. districts pur 6. GOI, Ministry of Health and Family Welfare, Cut 43.5 33.8 43.7 40.3 National Health Policy, 2017. before 7. India Newborn Action Plan, Ministry of Health placental and Family Welfare, GOI, September, 2014 delivery 8. National Neonatology Forum teaching aids, Cut after 56.5 66.2 56.3 59.7 newborn care, 2015. www.nnfi.org/index.php placental 9. National Family Health Survey, NFHS-4, IIPS, delivery Mumbai, GOI, 2015-16. Similarly, only less than 45% of ASHAs across the 10. David Osrin, Kirti M., et. al., 2002; Cross- four districts replied that the cord should be cut sectional, community based study of care of before placental delivery. It was only 34% in newborn infants in Nepal, BMJ 2002:325:1063 Barabanki district. This showed that the rest 55% of 11. Ved, et. al,. 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1487 Academy of Social Science Journals, vol. 4, Issue 11, November, 2019 Tridibesh Tripathy / Knowledge of ASHAS in New Born Care Practices in Relation to Placental Delivery in Uttar Pradesh, India doi; 10.1016/s0140-6736 (08) 61483- Xpmid:1892677. 13. GOUP, NHM, PIP, 2007-2008 14. Kelly et.al, Community health worker performance in the management of multiple childhood illnesses, Siaya district, Kenya, 1997- 2001, AJPH, Vol 91, No.10, 2001.

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