How to TrainCommunity Health Workers in Home-Based … 1... · · 2012-10-05How to TrainCommunity Health Workers in Home-Based Newborn ... Working in the Community and Visiting

How to Train Community Health Workersin Home-Based Newborn Care

Training Manual

By

The SEARCH Team

Abhay Bang, MD, MPH

Priya Paranjpe, M.Sc., M. Ed.

Sanjay Baitule, DHMS

In collaboration with

Judith Standley, CNM, MPH

Volume 1 :Introduction

Module 1 : Introduction to Newborn Health and Care

Module 2 : Working in the Community and Visiting During Pregnancy

Module 3 : Treating Minor Ailments in the Community (Part I)

Editorial staff : Robin Bell, Charlotte Storti, Julia RubenEditorial consultant : Deborah ArmbrusterReviewers : Barbara Kinzie, Betty Farrell, Bob Parker, Dave Woods Frank Anderson, Joy Lawn, Milly Kayongo, Steve Wall, Susan Goldman, Susheela Engelbrecht

Illustrations : Anil Barsagade, GadchiroliOther illustrations : Sources acknowledged

Press : Narayan Offset Works, Nagpur

First edition : January, 2006

Produced and published by SEARCH,(Society for Education, Action and Research in Community Health)Gadchiroli - 442605, IndiaE-mail : [email protected]

© Society for Education, Action and Research in Community Health (SEARCH), 2006

Any part of this training manual including the illustrations may be copied, reproduced or adapted tomeet local needs provided the parts reproduced are distributed not for profit and the source isacknowledged. For any reproduction for commercial purpose permission must first be obtained from theDirector SEARCH, Gadchiroli. SEARCH would appreciate being sent a copy of any material in which textor illustrations from this manual have been used.

This publication was made possible through support from -

The Ministry of Health and Family Welfare, Government of India, The Saving Newborn Lives Initiative of Save the Children (USA), and The Bill & Melinda Gates Foundation.

CONTENTS Page Number to be added

Vol 1 :ForewordAcknowledgementAbbreviations

Introduction How to Use This Manual 1-3 Training Schedule and Alternatives 4-6 Home-Based Newborn Care 7-16 Job Description of Community Health Worker and Training Objectives 17-19 The CHW Kit : Equipments and Medicines 20-22

Training Workshop 1Module 1 : Introduction to Newborn Health and Care 27-39Module 2 : Working in the Community and Visiting During Pregnancy 40-99Module 3 : Treating Minor Ailments in the Community (Part I) 100-113

Training Workshop SummaryPlanning for work in the community and the evaluation at worksite. Modules 1,2 and 3 114-115

Vol 2 : Training Workshop 2Module 4 : Observing Labour and the Newborn at Birth 119-146Module 5 : First Examination of the Newborn 147-181Module 3 : Treating Minor Ailments in the Community (Part II) 182-192Module 6 : Stock Keeping and Treatment Records 193-205

Training Workshop SummaryPlanning for work in the community and the evaluation at worksite Modules 3 , 4, 206-2105, and 6

Vol 3 : Training Workshop 3Module 7 : Making Home Visits to Newborns 213-235

and the Care of Eyes, Skin and Cord

Training Workshop SummaryPlanning for work in the community and the evaluation at work site: Module 7 236-238

Vol 4 : Training Workshop 4Module 8 : Acute Respiratory Infections 241-283Module 9 : Interpersonal Communication 284-304

How to Train Community Health Workers in Home-Based Newborn Care

Module 10 : Injecting Vitamin K 305-315

Training Workshop SummaryPlanning for work in the community and the evaluation at work site: Modules 8, 9, 316-319and 10

Vol 5 : Training Workshop 5Module 11 : Breastfeeding 323-366Module 12 : Using visual aids for health education 367-391

Training Workshop Summary Planning for work in the community and the evaluation at worksite - modules 11 and 12 392-394

Vol 6 : Training Workshop 6Module 13 : Prevention and Management of Hypothermia 397-416Module 14 : High-Risk Assessment and the Management of Low Birth Weight/ 417-441

Preterm Babies

Training Workshop Summary Planning for work in the community and the evaluation at work site: Modules 13 and 14 442-444

Vol 7 : Training Workshop 7Module 15 : Birth Asphyxia : Diagnosis and Management 447-487Module 16 : Neonatal Sepsis : Diagnosis and Management 488-536Module 17 : Referral and Review of Mother-Newborn Records 537-601

Training Workshop SummaryPlanning for work in the community and the evaluation at worksite - modules 15, 16, 602-603and 17

Vol 8 : Final Evaluation and Certification

Evaluation of CHW training 605-606CHW written test 607-614Evaluating CHWs on the attitudes and strengths 615-619CHW progress book 620-626Training evaluation field guide 627-635

Other Educational Aids included in the package (CD)

How to train community health workers in home-based newborn care : Training Manual on CDHow to train TBAs to support home-based newborn careHealth education flip chart : Dialogue with mothers


FOREWORDThis training manual was developed by a team from SEARCH, a nongovernmental organization based

in Gadchiroli, Maharashtra, India, and further field-tested through the Ankur project at seven differentNGO sites in Maharashtra state. It is an impressive and clear set of materials for training village healthworkers to deliver basic yet comprehensive home-based neonatal care at the community level. In an isolatedrural area of India with limited access to other health care services, the original SEARCH project which haddeveloped this home-based neonatal care approach was able to reduce the neonatal mortality rate by over60 percent. From the experience in the Ankur field test, the training was assessed as “extremely effective”in an extensive evaluation.

Designed to be adapted to various conditions and interventions, this manual will be an important tooland an invaluable resource for other programs engaged in developing curricula and training activities inhome-based neonatal care. Regardless of local conditions, however, the SEARCH team found two principlesto be critical to the success of this program. First, training sessions, which relied heavily on participatorytraining approaches, were conducted over a number of months and interspersed with periods of supervisedhands-on field practice. Second, the technical content was presented in a deliberate sequence, from simpleto more complex, with each component building on previous ones. From my own experiences in developingcountries, particularly India and China, these two aspects are critical for effective training of health workers,particularly those with limited or basic education and little or no prior health care training or experience. Inaddition, a third principle—carefully focused refresher training carried out on a periodic basis and withsupportive supervision—is also essential to maintaining the knowledge and skills imparted by the initialtraining program. Although not a part of this manual, refresher training and effective supervision have alsobeen critical to the success of the SEARCH and Ankur projects.

For those who anticipate adapting and using this manual, it is important to understand the context inand for which it was developed, especially the challenges and opportunities in working at the communitylevel in India. For more than 20 years, Drs. Abhay and Rani Bang, and more recently their team in theSEARCH and Ankur projects, have been committed to working in Maharashtra to solve the health careproblems of rural, tribal, and urban slum communities. Their approach begins with helping the communityidentify and understand their health care needs and participate in developing and implementing solutions.As scientists, they worked to ensure careful documentation of health care problems, the processes in carryingout interventions (including training), and the effect of any intervention. They found that it is important todocument results from community interventions in terms that would be understood by and carry weightwith policy makers and program managers and would, therefore, be useful for advocacy and replication inother places.

It is important to note that the materials in this manual were not developed in a limited or staticsituation; they were developed, rather, through a dynamic and iterative process that is necessary for anycommunity-based activity. Through a combination of known and feasible health care practices, experiencein participatory training approaches, and trial and error, SEARCH developed the basic materials andapproaches as the original interventions evolved over several years. The credit for this achievement belongs


not only to the leaders of SEARCH and Ankur, but to the field staff of the projects for their inputs andsuggestions, particularly the village-level health workers and their supervisors who were the real targets ofthe training. The final team responsible for putting this manual together included:Dr. Abhay Bang, the director of SEARCH, Priya Paranjpe, the training expert at SEARCH, and Dr. SanjayBaitule, the SEARCH medical officer—in collaboration with Judith Standley, an international consultantwith valuable experience in developing manuals for village-level training programs in India and China.

In any activity based on a specific setting and program, the ability to sustain and replicate the resultsare relevant issues. Within the SEARCH and more recently the Ankur settings, the training program andapproach have now been sustained for almost ten years, albeit in a dynamic and evolutionary manner. Thelesson for other programs and projects is that training and training programs cannot remain static; theymust have the flexibility to evolve and adapt to the experiences and changing conditions of each setting.Successfully replicating this training program depends on recognizing that the program is both a technicalpackage, with a particular focus on staging and participation, and, most importantly, a philosophy ofcommunity participation that forms the basis for true acceptance, utilization and support of the healthworkers being trained.

Robert L. Parker, MD, MPH

Senior Research AdvisorSaving Newborn Lives InitiativeSave the Children, USA

Adjunct Associate Professor, International HealthJohns Hopkins University Bloomberg School of Public HealthBaltimore, MD


AcknowledgementThis training manual and the training method, are products of the efforts of many individuals and

organisations. We especially acknowledge the 39 community health workers in the Gadchiroli field trialand the members of SEARCH, especially Dr. Rani Bang, Dr. Hanimi Reddy, Mr. Mahesh Deshmukh, Dr.Pradeep Paranjpe, Ms. Kusum Gadpayle, Kausalya Rode and Sunanda Khorgade.

Seven non-government organisations who participated in the ANKUR project of replicating the Home-Based Newborn Care, the Indian Council of Medical Research staff from the pilot sites in five states werethe next participants in the training. They and their community health workers contributed in the evolutionof this training.

Anil Barsagade of Gadchiroli drew many sketches and Hemant Pimpalkar looked after the preparationof the final press copy. Robin Bell, Charolotte Storti and Julia Ruben, the editorial team of Saving New BornLives, and Deborah Armbruster the editorial consultant helped in shaping this manual.

The draft manual was received by Barbara Kinzie, Betty Farrell, Bob Parker, Dave Woods, FrankAnderson, Joy Lawn, Milly Kayongo, Steve Wall, Susan Goldman, Susheela Engelbrecht.

Mr. Bhushan Banhatti of the Narayan Offset Works, Nagpur printed these volummes.

Dr. Bob Parker guided the process of producing this manual.

We are grateful to the Saving Newborn Lives of Save the Children, US and its executive director Ms.Anne Tinker, the Bill and Melinda Gates foundation, and the Ministry of Health and family welfare,Government of India, for financially supporting the process of developing and producing this trainingmanual and the package.

A BP PS BJ S


LIST OF ABBREVIATIONS

ANC Antenatal care

ANM Auxiliary nurse midwife

CHW Community health worker

Cotra Cotrimoxazole

EDD Expected date of delivery

G.V. Paint Gentian violet paint (solution)

HBNC Home-based newborn care

HO Handout

IMR Infant mortality rate

IPComm Interpersonal communication

LBW Low birth weight

LMP Last menstrual period

NCS Newborn care supervisor (trainer/supervisor)

NGO Nongovernmental organization

NMR Neonatal mortality rate

PHC Primary health center

TBA Traditional birth attendant

TT Tetanus toxoid

VSS Vital statistics supervisor

How to Train Community Health Workers in Home-Based Newborn Care 1

How to Use this ManualBackground

This manual is based on the programme developed by SEARCH to train community health workers(CHWs) in home-based newborn care (HBNC) in Gadchiroli District, Maharashtra, India. The success of theprogramme—a significant reduction in neonatal mortality—led to replication of the SEARCH HBNC modelprogramme by other nongovernmental organizations (NGOs) through the Ankur Project, supported bySave the Children US. During the implementation of the Ankur Project, this manual was field-tested byseven NGOs in Maharashtra state, where 100 new CHWs were trained. Using CHWs’ actual experiencesduring the training, the manual was revised to make it more effective and user friendly. The manual wasthen sent to a number of national and international experts in newborn health for review. The revisedversion was translated into Hindi, Marathi and Oriya languages and used in the field trial in 5 states by theIndian Council of Medical Research. The experience gained was used to further improve this version of themanual.

The Home-Based Newborn Care Training Package

This manual is a part of the home-based newborn care training package developed to assist organizationsor governments in implementing this approach in communities. The package consists of:

1. A manual for training CHWs in Home-Based Newborn Care: including CHW Progress Book Photograph album of newborn conditions and congenital anomalies Health education flipchart Health education film in Hindi (Nanhisi Jaan) and Marathi (Tanhula) Survey forms and newborn health records

2. Training of trainers (TOT) manual for home-based newborn care (Under preparation)3. Traditional birth attendant (TBA) manual for home-based newborn care

Training Philosophy

The philosophy of this training manual is strongly participatory and based on learning-by-doingactivities. The CHWs in both the SEARCH and Ankur programmes are women with limited education,some having as little as four years of schooling (although a few have up to 12 years). As all of these womenare adults, they bring a range of experiences to the classroom that enriches the training programme. Thevast majority of these women are married and have children.

In order to ensure that all participants are included in the learning process, the training activities in thismanual focus on adult learning methods that require participation, including large and small group discussions,role plays, demonstrations, games, case presentations, case studies and practice in both the classroom andin communities. Some of the training material was adapted after experience in the field, such as the CasePresentation used for filling in forms. When the case was written as a narrative (a story with many details),

2 How to Train Community Health Workers in Home-Based Newborn Care

the participants had a lot of difficulty finding the information needed to fill in the form. Since the objectiveof the session was to fill in the form correctly, the case presentations were modified to list in a more simpleway all the necessary data. This proved a much more effective method for the particular objective.

In the Ankur project, the trainers who used this manual were mostly graduates. Since many trainersdid not have significant teaching experience, the manual is very detailed, giving step-by-step instructionsto trainers and providing them with ready-made training aids and tools such as model role play scriptsand skill checklists.

Because of the need to upgrade their training skills and to maintain the quality of the programme,trainers are encouraged to undergo the training-of-trainers course prepared by SEARCH as a prerequisiteto using this manual.

Eligible Trainers

The personal qualities and attitudes (openness, ability to communicate, respect and empathy fortrainees), and the willingness to train village women (CHWs) are very important eligibility criteria.Professional background of the trainers should be diverse. In the experience of SEARCH, a team ofthree persons makes the ideal combination of trainers. 1) a doctor (MBBS or non - MBBS), 2) anurse and 3) a social worker.

Layout of the manual

Each of the seven training workshops is ring bound in a separate volume. A schedule for the workshopfollows , and the modules to be taught during that training workshop follow the schedule.

Each module contains extensive trainer notes or lesson plans. The trainer notes are a guide to what willhappen during that session. The notes include:

objectives of the session time required for the session materials/preparation needed for the session training methods to use the content of the session how to summarise the session how to evaluate if the objectives have been met

The materials section lists all training aids, handouts, checklists, etc. that are needed for the particularsession. The materials listed are found on the pages immediately following the trainer notes.

At the end of each training workshop there is a guide for the trainer to use to evaluate each CHW’sskills as demonstrated during her practical work in the community.


Adapting the Manual for Use in Other Contexts

This training manual was developed for training in the state of Maharashtra, India. The supervisor hasto spend 8 hours per day per 20,000 population. For use in other parts of India, some of the role plays andcase studies may need to be adapted to reflect local names, foods, etc. In countries other than India, it isrecommended that the whole manual be reviewed and revised as necessary. Checklists should be reviewedto agree with any local protocols, and all stories, case studies, and model role play scripts, should beadapted to reflect local customs. Although the manual is technically sound, it will be important to make itmore culturally relevant to increase acceptance and ensure a successful training outcome.

To make this adaptation easier, a CD of the training manual has been incorporated in the manual.

Abhay BangPriya PraranjpeSanjay BaituleJudith Standley


Training Schedule and the AlternativesTraining during the Ankur project was divided into seven training workshops spread out over a

period of one year. This was done deliberately so that CHWs were introduced to a limited amount ofinformation and skills during a training workshop and then given time to practice the new skills in theircommunities under guidance from their supervisors. Allowing the CHWs time to absorb one set of skillsbefore learning another, worked very well and was consistent with SEARCH’s strategy of introducinginterventions into the community.

The CHWs in ANKUR were first taught skills in collecting basic data (communication skills, how toexamine a newborn, how to fill in forms, etc.). After they practiced data collection, intervention skillswere taught and practised, including counseling for breastfeeding, keeping the newborn warm, identifyingand treating the high-risk baby, identifying and treating asphyxia, and identifying and treating infection.

The manual is divided into seven training workshops containing a total of 17 modules. The sequenceof the modules and the grouping of topics have been carefully planned for maximum learning and whiletrainers are encouraged to follow the sequence, the manual is flexible and changes can be made whenneeded. In making changes, however, it would be best to bear in mind the overall rationale for the order ofthe sessions in the manual.

The CHW must be accepted as a useful person by the entire community. Treating minor illness istherefore included in the first training workshop to enable the CHW to be immediately helpful toanyone in the community, not just pregnant women and newborns.

Early skills are designed to be building blocks for more complex tasks. For instance, diagnosingand managing acute respiratory infections with co-trimoxazole and giving vitamin K injections aretaught in Workshop 4 so the CHW masters these skills before she learns sepsis management.

Most of the modules are taught in one training workshop, with the exception of Module 3, TreatingMinor Problems, which is spread out over the first two workshops. The planners felt that the CHW wouldbe accepted more readily by the community if she could attend to minor problems—headache, body ache,and minor wounds—from the very beginning of her training.

With further experience, SEARCH felt the need for more flexible training schedule for the diversesituations. Hence, three different training schedules covering the contents of this manual are suggested.In the third alternative, it is assumed that the CHW, who is already working, has been trained in the basictasks such as making the list of women in the community, making list of pregnant women and registeringthem, and treatment of minor ailments in the community. Hence module 3, 6 and a part of module 2 havebeen deleted.


The place Jan Feb Mar Apr May Jun Jul Aug Total Daysof training

Training TW 1 TW 2 TW 3 TW 4 TW 5 TW 6 TW 7 RevisionWorkshop 5 days 4 days 2 days 4 days 3 days 3 days 4 days + Final 30 days

+ Revision + Revision Evaluation1 day 1 day 3 days

Total field 24 days 22 days 26 days 24 days 25 days 25 days 25 days 27 days 198 dayspracticein thecommunity

Field Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer 16 daystraining visits visits visits visits visits visits visits visitsunder 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 dayssupervision

* TW - Training Workshop

Plan 2 : A fast paced plan of training newly inducted CHWs (spread over 7months)

Plan 1 : For training newly inducted CHWs (spread over one year)

The place Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Dec Totalof training Days

Training TW 1 TW 2 TW 3 Rev Tr1 TW 4 TW 5 RevTr2 TW 6 TW 7 Rev Tr3Workshop 5 4 2 2 4 3 2 3 4 + Final 32

days days days days days days days days days evaluation days3 days

Field 24 22 27 26 25 25 27 26 24 29 28 26 309practice days days days days days days days days days days days days daysin thecommunity

Field Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer Trainer 24training visits visits visits visits visits visits visits visits visits visits visits visits daysunder 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days 2 days

supervision


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Home-Based Newborn Care

I shall give you a talisman. When you are in doubt, or when the self becomes toomuch in you, bring before your eyes the weakest, most wretched and miserable humanbeing that you ever saw, and ask yourself, that the step you contemplate, "Will itreduce his misery? Will it reduce his helplessness?" You will get your answer.

Mahatma Gandhi

In Gadchiroli district, about 1,000 kilometers fromthe state capital, Mumbai, (Fig 1) SEARCH (Society forEducation, Action and Research in Community Health)has developed a model of home-based newborn care,which, in a controlled trial, showed significant reductionin newborn and infant mortality in the villages of thispoor, remote area1.

The Challenge

SEARCH had introduced community-basedmanagement of pneumonia in children in 1988 withexcellent results2. By 1992, the team realized that ofthe residual infant mortality rate (IMR) of 80 per 1000live births, neonatal mortality rate (NMR) contributed75 percent. Recognizing that hospital-based care forsick newborns was not possible in their community,SEARCH conceived the innovative idea of a home-based newborn health care. Care had to be home-based because a) 83 percent of births in rural India occurred at home, b) more than 90 percent of parentswere unwilling to go to hospital for treatment of a sick newborn3; c) local doctors were not trained tomanage sick newborns, and d) hospital care was inaccessible to and too costly for most rural communities.

Testing the Solution

In response to this problem situation, SEARCH developed the concept of newborn care to be providedat home by village women. Will this approach be successful? SEARCH designed a field trial to test thefeasibility and effectiveness of home-based newborn care (HBNC).

The study began by collecting baseline data for two years (1993-1995) from 39 intervention villagesand 47 control villages. The baseline NMR was 62 and 58 respectively1. One year of observing newborns intheir homes provided the first estimates of morbidities in rural newborns. While 54 percent of newborns

Nagpur

New Delhi

MaharashtraMumbai

GadchiroliDistrict

Fig. 1Gadchiroli in India


needed medical attention, only 2.6 percent received it, and only 0.4 percent were hospitalized4. The maincauses of death in newborns were infection (sepsis / pneumonia) 52%, asphyxia 20%, and preterm birth15%. The research team then introduced home-based newborn care in the intervention villages (1995-1998)and monitored mortality rates in both the control and intervention villages.

What is Home-Based Newborn Care?

The key providers of newborn health care in SEARCH's model are women from the community -mothers and grandmothers - supported by trained community health workers (CHWs) and traditionalbirth attendants (TBAs). The CHWs visit each woman three times during her pregnancy, provide healtheducation, attend the delivery to care for the newborn, and visit 7 to 13 times during postnatal period tohelp the mother look after the newborn.

The CHWs are trained to resuscitate asphyxiated newborns, support breastfeeding and maintenanceof body temperature, and recognize and treat sepsis / pneumoia using antibiotics. They also provide careat home to high-risk newborns such as per-term or LBW. (See Fig. 2, & Box 1 )

TBAs receive training and are supplied with clean delivery kits and eye ointment for preventingnewborn conjunctivitis. CHWs and TBAs work in collaboration. The CHWs are paid an honorarium linkedto their workload and performance.

Fig. 2 : Home-based Newborn Care in Practice

Group health education Temperaturerecording

Weighing

Practising asphyxia management Sepsis managementAssisting in breast feeding

Home visit


Home-Based Newborn Care: The Contents

1. Selection and training of a community health worker in each village.2. Ensuring cooperation of community, TBA and the health services.3. Making a list of pregnant women in community, and updating it regularly.4. Health education:

Group health education: using audio-visuals and games. To individual mother, by home visiting; three times during pregnancy, on the second day

after delivery, and whenever indicated during the home visits. To mothers of high-risk newborns.

5. Attending delivery, along with the TBA. Encouraging the family and the TBA for referral when necessary. Taking charge of the baby immediately at birth. Assessment, and if necessary, management of asphyxia by following medically approved

algorithm, and using bag and mask.6. Initiation of early and exclusive breast feeding, and supporting/teaching mother to breast-

feed successfully.7. Thermal care of the newborn.8. Assessing for high-risk status. If present, extra care.9. Repeated home visits (7-13) during newborn period to ensure breast-feeding, thermal care,

hygiene, and to monitor the baby for any infection – superficial or systemic (sepsis).10. Early diagnosis and treatment of newborns with sepsis, including administration of two

antibiotics – co-trimoxazole and gentamicin.11. Home-based care of LBW or preterm newborns.12. Weekly weighing, problem solving, advising and helping mother.13. Referral of newborn or mother when necessary.14. Supervision (twice in a month), support, supplies, records, performance-linked remuneration

and training to CHWs.15. Vital statistics and HBNC service data monitoring.

Box 1

The Effects

By 1998, the third year of the intervention, 93 percent of newborns in the intervention area werereceiving home-based care. The vital statistics surveillance system of SEARCH was independently recordingbirths and child deaths in the area. While the NMR in the control area remained at around 60 per 1,000 livebirths, the NMR in the intervention area dropped from 62 to 25 per 1,000 live births - a 62 percent reductioncompared to the control area. The IMR was also reduced by nearly half to 391. (Table 1).


Table 1

Effect on Mortality(Gadchiroli, 1993 - 98)

Rate Control Area Intervention Reduction(Per 1000 Live births) Baseline Intervention Year Baseline Intervention year

(1993 - 95) (1997 - 98) (1993 - 95) (1997 - 98)

Neonatal Mortality 58 60 62 26 62%RateInfant Mortality 77 75 76 39 46%Rate

(Lancet 1999)

The other major effects of HBNC were:

Beliefs and behaviors of mothers about newborn care improved significantly. The incidence of various newborn morbidities (especially infections,

breastfeeding problems, hypothermia and mild birth asphyxia) declined overall by49 percent5.

Case fatality dropped steeply in the preterm LBW newborns by nearly 60percent as well as in the newborns treated for sepsis / pneumonia6,7. (Fig. 3)

Maternal morbidities during labor and postpartum period declined significantly, thereby establishingthe feasibility of combining home-based postpartum care of mothers with newborn care.

0

5

10

15

20

25

30

35

40

45

Low birth weight Preterm Sepsis Asphyxia

1995-96, Before interventions 1996-03, With interventions** : p < 0.005, * : p < 0.07

11.3

4.9**

33.3

10.1**

18.5

6.9**

38.5

20.2*

Fig. 3 : Effect on Case Fatality


The total effect of this approach (pneumonia management from 1988 and HBNC from 1995) on the IMR in39 intervention villages is shown in Fig. 48.

Can it be done elsewhere?

Based on these remarkable results, the ANKUR projecthas been launched by SEARCH in collaboration with sevenlocal NGOs and with financial support from Save theChildren's 'Saving Newborn Lives Initiative'. The aim is toexamine the potential of replicating this successful model inother communities in Maharashtra state as a prelude toscaling up in other regions of India. The seven project sitesinclude urban and tribal communities as well as ruralpopulations. (Fig. 5)

The Ankur project began in 2001. Baseline mortalityrates were collected, and then the CHWs were selected. Anoutstanding feature of the Ankur project was the stagedparticipatory training program for CHWs, TBAs and theirtrainers - a process that has produced capable and confidentCHWs. These CHWs scored 86 percent marks on average in the final training evaluation. Their skills havebeen recognized and their communities now request their services. This rapid community acceptance of theCHWs and home-based newborn care in the NGO study sites was impressive. SEARCH and Saving Newborn

Fig. 5 : Project ANKUR in Maharashtra

SEARCH

Selected Study sites

Fig 4: Effect on the Infant Mortality Rate(39 villages, Gadchiroli)


Lives, in a mid term evaluation in March 2003, were able to conclude that the ANKUR project - at least in itspreliminary stage - has shown that home-based newborn care can be replicated by NGOs. The nationalleadership of pediatricians and the Health Secretary, Government of India. (Fig.6) conferred certificates toall CHWs and trainers assessed as competent.

Since replication of the home-based model in the Ankur project with NGOs has had positive results todate, the Government of India has initiated a pilot study conducted by the Indian Council of MedicalResearch (ICMR) in five states, to test how the HBNC model can be incorporated into a national program.

The contents and methods in this training manual are based upon the field trial in Gadchiroli and the ANKURproject and have been used to train the trainers, supervisors and CHWs in five states in the ICMR project.

Essential Ingredients for Successful Replication9

The coverage, quality and effectiveness of HBNC in the Gadchiroli trial were high. On looking back,the following ingredients are considered crucial for this achievement:

1. Community Consultation:

Newborn care was not a high priority for the adult males who usually articulate community needs.Moreover, due to their past experience, families had a fatalistic outlook towards the survival of newborns.

Fig. 6 : Health Secretary, Gov't of India and the national leaders of pediatricsassociations inaugurating the intervention in ANKUR project. (2003)


Hence, a wider consultation with community members, including women, to sensitize them to the need andthe possibilities of the new intervention of HBNC, is necessary.

2. Selection of CHWs:

This was probably the single most important decision for ensuring success at the community level. Anationwide CHW program in India failed nearly two decades ago and was finally stopped. The majorcauses were selection of inappropriate persons as CHWs (mostly males) and poor training. The method ofselecting CHWs in Gadchiroli (and followed in the Ankur project) involved setting eligibility criteria, widepublicity and community involvement to get the maximum number of eligible candidates, personality testingof the candidates in a 3 day workshop, objective evaluation and finally, testing in the field. This intensivemethod of recruiting yielded satisfactory results - high performance of CHWs and a < 15% dropout rate ineight years.

3. Training:

In the training strategy and the curriculum that we developed, a literate woman from a village, newlyselected as CHW, requires 32 days of classroom training, spread over a period of 12 months or 29 days oftraining spread over a period of 7 months (Refer the training plan on page no. ). This gives her theopportunity to learn in small doses (three to five days in each month) and to practice incrementally thesenew skills in the community (in which about two births occur every month) under the guidance of a visitingfield supervisor. This ensures that the training is practical and of good quality, and is based on actual tasksshe will be doing. Moreover, the CHW is trained in the setting where she will be working. The communitybecomes the ground for learning clinical and communication skills.

4. Supervision:

Field supervision (two visits in each month to each CHW) is a crucial component of the HBNC. Itshould be viewed as an extension of training and support to CHWs rather than inspecting. It should resultin improved skills, motivation and performance of CHWs, problem solving and community support. Thetime requirement for the work of supervision is 8 hours per day per 20,000 population.

5. Performance Linked Remuneration:

The result of time motion study done in ANKUR shows that the CHW has to give 1 hour 23 minutestime per day per 1000 population to provide services to the newborns and mothers in the area and hence itis not a full time job. Families, at least for now, were unwilling to pay for the services to the newborn.Hence, the CHW has to be financially supported. In both the Gadchiroli and Ankur projects, the CHWsremuneration was kept marginally more than the wages she might earn as an agricultural laborer in thesame number of hours. This ensures that the rural elites did not vie for the job, but at the same time,ordinary village women find it attractive to take up this new job.

The CHW's total expected remuneration is divided so that approximately one-third is a fixed monthlypayment (retention price) and two-thirds is linked to her performance. A payment scale using workoutput and the work quality has been developed. We find this to be very effective in motivating the CHWs


and for ensuring good performance.

6. Motivation and Empowerment:

Apart from the remuneration, the newly acquired skills and new role give the CHW recognition inher community. This, combined with the respect she receives from her supervisors and program managersand, finally, the emotional gratification she gets by helping mothers and newborns in her own communityare powerful motivators and sources of empowerment.

7. Acceptance and Utilization:

HBNC covered 93% of newborns in the intervention area in Gadchiroli. The CHWs were present for84% of the home-deliveries. Most families were willing to allow for management of sick newborns, includingof LBW, preterm newborns and those with sepsis, to take place at home. The crucial elements for highacceptance were:

i) An unserved area in which 95% of deliveries occurred at home. (However, in the ANKUR projectit was found that even in the areas with a higher proportion of hospital deliveries, most of the post-partum/newborn period is spent at home. Therefore, HBNC is needed even in such areas.)

ii) Selection of a woman acceptable to the community as the CHW.iii) 24 hour availability of the CHW.iv) Cooperation of the TBA who was made to feel supported and not threatened by the arrival of an

additional hand.v) The curative role of the CHW (treatment of minor illnesses of adults, management of diarrhoea

and pneumonia in children, management of asphyxia and sepsis in newborns, administration ofvitamin k injection to all newborns), and reduced case fatality.

Replication and Improvisation Initiatives in South Asia

i) In two national workshops (1999 and 2003) the national leadership of pediatricians and neonatologistsin India endorsed the HBNC approach and recommended its wider application.

ii) Development of the training curriculum, manuals and health education material for training inHBNC has been completed by SEARCH, Gadchiroli. The evaluation of the training in seven differentfield sites showed that 92% of the trained CHWs scored > 70%. As a result, the training has beennow standardized.

iii) Replication through government health services is a major research issue. A field trial (2003-2007)by the Indian Council of Medical Research at the behest of the Ministry of Health and FamilyWelfare, Government of India, is field testing the HBNC approach in five states in India, using theintervention package and training developed in the Gadchiroli trial and further tested in the Ankurproject.

iv) The new five-year national project, Reproductive and Child Health (RCH-II) of the Government ofIndia (2005-2010) proposes the introduction of the HBNC approach in a substantial part of thecountry.

v) The IMCI program in India is being modified to include a home-based newborn care componentusing a similar approach and has become an "IMNCI" i.e. Integrated Management of Newborn andChildhood Illnesses.


vi) New field trials have been launched to test the feasibility, replicability, and sustainability of HBNCin communities in Bangladesh, Malawi, Nepal and Pakistan.

Beyond the Old Boundaries, a New Role:

Management of a high-risk or sick newborn is usually considered a difficult and specialized job. Thoughtheoretically sound and well meaning, this position may result in a "touch-not a newborn" mindset amonghealth workers. The Gadchiroli trial shows that by using the method of task analysis, the complex job ofnewborn care can be broken down into a series of smaller, simpler tasks and the CHWs can be trained tosuccessfully undertake these tasks.

This new role involves some unconventional tasks, such as the management of birth asphyxia with bagand mask, administering injection vitamin K, management of LBW babies, clinical diagnosis of sepsis usingspecific criteria and managing sepsis with two antibiotics, including the administration of gentamicin byinjection. With proper training and supervision, these tasks can be done well in home settings by a CHW asdemonstrated in this trial.

A trained CHW is not a skilled birth attendant; but she is also not an illiterate traditional attendant.She may be called "a semi-skilled attendant". The evidence in this trial shows that by teaming up with TBA,mother and family, the CHW can provide newborn care, improve newborn survival, and as describedearlier, also improve maternal health in unserved areas.

The Talisman for Equity in Health Care

We began this chapter with a quote, "the talisman," by Mahatma Gandhi. A newborn in developingcountries undoubtedly is that weakest human being, its care the ultimate test of equity, human justice andhealth care.

Four million newborns die every year, most of them at home. If they cannot reach health services, thehealth services must reach out to them. The evidence from the Gadchiroli field trial suggests that suchreaching out is possible. This is the reason for writing this manual.


References

1. Bang AT, Bang RA, Baitule SB, et al. Effect of home-based neonatal care and management of sepsis onneonatal mortality : field trial in rural India, The Lancet (1999) Vol. 354 : 1955-61.

2. Bang AT, Bang RA, Tale O, et al. Reduction in pneumonia mortality and total childhood mortality by means ofcommunity based interventions trial in Gadchiroli, India The Lancet (1990) 336 : 201-06.

3. Bang AT, Bang RA, Morankar VP, et al. Pneumonia in neonates: can it be managed in the community? Archivesof Disease in Childhood (1993) ; 68 : 550-556

4. Bang AT, Bang RA, Baitule SB, et al. Burden of Morbidities and the Unmet Need for Health Care in RuralNeonates – A Prospective Observational Study in Gadchiroli, India, Indian Pediatrics Vol 38 : (2001) : 952-965.

5. Bang AT, Bang RA, Reddy HM, et al. Reduced incidence of neonatal morbidities: Effect of home-based neonatalcare in rural Gadchiroli, India. J of Perinatology (2005); 25: S51-S61.

6. Bang AT, Baitule SB, Reddy HM, et al. Low Birth Weight and Preterm Neonates: Can they be managed athome by mother and a trained village health worker? J of Perinatology (2005); 25: S72-S81.

7. Bang AT, Bang RA, Stoll BJ, et al. Is home-based diagnosis and treatment of neonatal sepsis feasible andeffective? Seven years of intervention in the Gadchiroli field trial (1996-2003). J of Perinatology (2005);25: S62-S71.

8. Bang AT, Reddy HM, Deshmukh MD, et al. Neonatal and Infant Mortality in the Ten Years (1993-2003) of theGadchiroli Field Trial: Effect of Home-based Neonatal Care. J of Perinatology (2005); 25: S92-S107.

9. Bang AT, Bang RA, Reddy HM. Home-based neonatal care: Summary and applications of the field trialin rural Gadchiroli, India (1993-2003). J of Perinatology (2005); 25: S108-S122.


Job description of Community Health Worker inHome-Based Newborn Care and Training Objectives

Upon successful completion of this training, the CHW will be able to:

1) Work effectively in the community and in smooth collaboration with TBAs

2) Visit every house in her village every six months and collect information on all marriedwomen of childbearing age and make or revise a list of women who may become pregnant

3) Visit all women who may become pregnant, once every two months to identify pregnant womenand register them (Pregnancy Form)

4) Organize and assist supervisors in conducting group health education for pregnant women every 6months in the village

5) Make two antenatal visits to all pregnant women in the village as follows:

a) At eighth (8th) month of pregnancy:i) Conduct health screening (Pregnancy Form)ii) Provide health education (using counseling cards appropriately) on:

(a) Nutrition during pregnancy(b) Danger signs in pregnancy and appropriate action(c) Provide health information sheet to expectant mothers

iii) Advise on taking iron and folic acid and tetanus toxoid from ANMb) At ninth (9th) month of pregnancy:

i) Conduct heath screening ((Pregnancy Form)ii) Provide health education (using counseling cards appropriately) on:

(a) Danger signs in pregnancy and labor and action to be taken(b) Planning for delivery(c) Breastfeeding

6) Attend delivery assist in referral when necessary and provide care at birth to the babya) Record information on delivery and birth (Delivery Form)b) Give emotional support to mother and familyc) Encourage/assist cleanliness, handwashing, use of new bladed) Assist TBA in referral when necessarye) Observe the newborn baby at 30 seconds after birth for cry, respiration, and movement of

limbsf) Determine whether the baby is normal or asphyxiated or is a stillbirth; and if the baby is

not normal, initiate asphyxia managementg) Dry and wrap the babyh) Observe the newborn baby at five (5) minutes (severe asphyxia) or 20 minutes (stillbirth)

after birth for cry, respiration, and movement of limbs


i) Initiate breastfeeding; assist as necessary for flat or inverted nipples.

7) Initiate management of birth asphyxia, if needed,a) By using mucus extractor, bag and mask (or tube and mask) as per requirementb) Determine if newborn is a stillbirth at 20 minutes after birth

8) Perform first examination of the baby one (1) hour after birth and complete the First Examination ofNewborn Form to determine whether the newborn is a high-risk baby

9) Provide care for the normal newborna) Share Danger Signs in Newborn information sheet with the family of the newborn and

explain the information sheet

10) Provide care for the high-risk newborna) Share High-Risk Baby information sheet with the family of the newborn and explain the

information sheet

11) Give vitamin K injection correctly

12) Conduct seven (5) regular home visits for mother and the normal newborn baby on days 2, 3, 7, 15,28 and additional days if the baby is sick on any other day, and fill out the:a) Home Visit Formb) Part I of the Newborn Health Care Evaluation form on day 2 and Part II by end of day 28c) Breastfeeding Problem Diagnosis form on each day of visitd) Sepsis Problem Diagnosis form on each day of visit

13) Conduct thirteen (13) regular home visits for mother and the high-risk newborn baby on days 2, 3,4, 5, 6, 7, 9, 12, 15, 18, 21, 24, 28 and additional days if needed, and fill out the:a) Home Visit Formb) Part I of the Newborn Health Care Evaluation Form on day 2 and Part II by end of day 28c) Breastfeeding Problem Diagnosis form on each day of the visitd) Sepsis Problem Diagnosis form on each day of the visit

14) Identify and manage the following problems in mother and newborn baby:a) Asphyxiab) Preterm birthc) Low birth weight < 2000 gramsd) Hypothermiae) Breastfeeding problemsf) Inadequate weight gaing) Neonatal sepsish) Pneumonia

15) Decide after 24 hours of initiating treatment (for some of above conditions) whether there isimprovement. If yes, continue treatment; if no, refer to hospital.


16) Continue home visits in second month (one visit every week) if at 28 days after birth the weight ofthe baby is less than 2 kg 300 gramsa) Complete second month Home Visit Formb) Initiate treatment for problems described in (13) above

16) Self-evaluate the care; identify successes and deficiencies (Newborn Health Care Evaluation Form)

17) Provide treatment to villagers for:a) Pneumonia in children under 5 years age

i) Repeat home visit to children receiving pneumonia treatmentii) Complete the Pneumonia Form

b) Basic care of wound and skin problemsc) Basic treatment for fever, headache, body ache

18) Maintain all registers and records

19) Maintain CHW kit and seek timely replacement/repair

20) Maintain medicine stock and seek timely replenishment

21) Work with the supervisor on the day of her visit

22) Work in cooperation with health care system or other health providers


Sr Medicines Use Quantity per CHWNo supplied initially1 Tablets Paracetamol 500 mg For children in community 1002 Tablets Acetylsalicylic Acid 300 mg (Aspirin) For community 5003 Gentian Violet paint 400 ml bottle (1%) Newborn Cord care 1 bottle4 Injection Gentamicin vial 80 mg x 2ml vial Neonatal sepsis 1 Vial

(40 mg per ml)5 Sterilised cotton 1 bundle6 Syrup Co-trimoxazole (Trimethoprim 40 mg Neonatal sepsis & 1 bottle

+ Sulphamethoxazole 200 mg/5 ml) pneumonia in children 7 Spirit 100 ml7 Tablet Salbutamol (4 mg) Children with wheeze 208 Injection vitamin K ampoule (10 mg / ml) Neonates 1 per newborn*9 Tetracycline eye ointment (3.5 mg) Neonates 1 per newborn*

* : Number of expected newborns may be estimated from the birth rate

Kit of the Community Health Worker to Provide Home-Based Neonatal Care

Sr Equipments Manufacturer Unit cost QuantityNo (Year 2002) per CHW1 Wrist watch - Rs 334/- 12 Digital Thermometer Becton & Dickinson B-D soft Rs 289/- 1

flexible digital thermometer3 Weighing Scale with sling Salter weighing Scale Model Rs 214/- 1

(Super Samson Capacity: 5Kg)4 Photo album of 13 reference SEARCH, Gadchiroli ---

photographs5 Bag and mask Zeal Medical Pvt. Ltd. Rs 923/- 16 Warm sleeping bag for Made to order as per SEARCH Rs 65/- 2-3

neonates. specifications7 Blankets for neonates - Rs 85/- 3-48 Kangaroo blouse for mother Made to order as per SEARCH Rs 99/- 2

specifications9 Mucus extractor Romson Rs 12/- 210 Health Education flip chart Made by SEARCH Rs 200/- 111 Baby feeding spoon - 212 Torch with cells - 113 Spoon - 114 Insulin Syringe - 515 Trunk for storage of kit, - 1

records etc. size 22"x 12"x 10"16 Bag for carrying Kit/material - 1

during home visit

Equipments

Medicines


Group photograph of Gadchiroli CHWs

Health Education flip Chart Weighing

Bag and MaskMucus Extractor

Syringe Ampoule ofInjection Vitamin K

Wrist watch

Cotrimoxazole

Tube and mask

InjectionGentamicin


PaladayDigital thermometer

Gentian Violet solution Photo album Warm bag

Tetracycline eye ointment

Blanket

CHW bag to carry kit onhome visit

Sterile cotton, paracetamol,sodamint, Salbutamol and

aspirin tabletsSoap for handwashing

Trunk for CHW kitBaby in Kangaroo blouse

TRAINING WORKSHOP : 1

CONTENTS

Module 1 : Introduction to Newborn Health and Care

Session 1 : Traditional customs, beliefs and terminology in local 27communities surrounding childbirth and newborns

Training Aid 1 : Small group exercise 30Session 2 : Introduction to home-based newborn care (HBNC) 31

Training Aid 1 : Role and responsibility game 36Training Aid 2 : Visualization exercise 38

Module 2 : Working in the Community and Home - Visitingduring Pregnancy

Session 1 : Working in the community 40Training Aid 1 : Model role play script 43

Handout 1 : Communication guide 45Session 2 : Talking with women in the community (practice) 46Session 3 : Preparing the list of all women in the village who may get 49

pregnantHandout 1 : List of all women in the village who may get pregnant 51Session 4 : Preparing the register book to record the list of all women 52

in the village who may get pregnantSession 5 : Determining the date of last menstrual period (LMP) 54

Training Aid 1 : Model role play script: Determining LMP 56Handout 1 : The circle aid for determining LMP 58Session 6 : Determining the expected date of delivery (EDD) 59Handout 1 : The chart to determine EDD and preterm based on the LMP 62Handout 2 : Measuring strip to determine the change in year 65Handout 3 : EDD worksheet 66

Training Aid 1 : Answers to EDD worksheet (HO-3) 67Session 7 : Preparing the list of pregnant women 68Handout 1 : List of pregnant women 70Session 8 : Home visiting and use of the Pregnancy Form – Part I 71Handout 1 : Pregnancy Form – Part I 75Handout 2 : Excercises to determine abortion, stillbirth, and neonatal death 76

Training Aid 1 : Answers to excercises to determine abortion, stillbirth, and 77neonatal death

23

Handout 3 : Worksheet to determine number of pregnancies and births 78Session 9 : Home visiting and use of the Pregnancy Form – Part II 81Handout 1 : Pregnancy Form – Part II 84Handout 2 : Photograph of swollen face and hands in pregnancy 86Handout 3 : Case presentations 87

Session 10 : How the CHW relates to the Traditional Birth Attendant 88(TBA)

Training Aid 1 : Model role play script: TBA-CHW relationship 91Session 11 : Field practice and use of the Pregnancy Form 93

Handout 1 : Pregnancy Form complete 95Session 12 : Qualities of an ideal CHW 97

Training Aid : Story to inspire CHWs 99

Module 3 : Treating Minor Ailments in the Community (Part I)

Session 1 : Cleanliness and handwashing by the CHW 100Handout 1 : Handwashing checklist 104Session 2 : Basic Care of Wound and Skin Problems 105Handout 1 : Basic Care of Wound and Skin Problems 108Session 3 : Using aspirin and paracetamol 109Handout 1 : Treating with aspirin and paracetamol 112

Training Workshop 1 SummaryPlanning for work in the community 114Post-training evaluation of CHWs at the work site: Modules 1, 2, and 3 115

24

TIM

E

TA

BL

ET

RA

ININ

G

WO

RK

SH

OP

1

OF

T

HE

CH

W

TR

AIN

ING

MO

DU

LE

S 1

, 2,

and

3

Day

1

Wel

com

eIc

e Br

eake

r (15

min

.)M

odu

le 1

: Int

rod

ucti

on to

New

bor

n H

ealt

h a

nd

Car

eSe

ssio

n 1:

Tra

diti

onal

cust

oms,

bel

iefs

and

term

inol

ogy

in lo

cal

com

mun

ities

abo

utch

ildbi

rth

and

new

born

s(1

hr 1

5 m

in)

Sess

ion

2: In

trod

uctio

n to

hom

e-ba

sed

new

born

car

e(H

BNC

) (3

0 m

in)

TEA

Sess

ion

2 (c

ontin

ued)

:In

trod

uctio

n to

hom

e-ba

sed

new

born

car

e (5

0 m

in)

Mod

ule

2 W

ork

ing

in th

eC

omm

unit

y an

d H

ome

-V

isit

ing

Dur

ing

Preg

nan

cySe

ssio

n 1:

Wor

king

in th

eco

mm

unity

(55

min

)LU

NC

HSe

ssio

n 1

(con

tinue

d) :

Wor

king

in th

e co

mm

unity

(20

min

)

Sess

ion

2: T

alki

ng w

ithw

omen

in th

e C

omm

unity

(pra

ctic

e)(1

hr

)TE

ASe

ssio

n 3:

Pre

pari

ng th

e lis

tof

all

wom

en in

the

villa

gew

ho m

ay g

et p

regn

ant (

1 hr

15 m

in)

Eva

luat

ion

Vis

ualis

atio

n ex

erci

se

Day

2

Song

Rev

iew

of p

revi

ous d

ay(1

0 m

in)

Sess

ion

4: P

repa

ring

the

regi

ster

book

to re

cord

the

list o

f all

wom

en in

the

villa

ge w

ho m

ayge

t pre

gnan

t (5

5 m

in)

Sess

ion

5: D

eter

min

ing

the

date

of la

st m

enst

rual

per

iod

( LM

P)(4

5 m

in)

TEA

Sess

ion

5 (c

ontin

ued)

:D

eter

min

ing

LMP

(1 h

r)

Sess

ion

6: D

eter

min

ing

the

expe

cted

dat

e of

del

iver

y -

EDD

(45

min

)

LUN

CH

Sess

ion

6 (c

ontin

ued)

:D

eter

min

ing

the

expe

cted

dat

eof

del

iver

y (E

DD

) (4

0 m

in)

Sess

ion

7: P

repa

ring

the

list o

fpr

egna

nt w

omen

(50

min

)

TEA

Sess

ion

7(c

ontin

ued

) :Pr

epar

ing

the

list o

f pre

gnan

tw

omen

(20

min

.)

Sess

ion

8: H

ome

visi

ting

and

use

of th

e Pr

egna

ncy

Form

- P

art I

(55

min

)

Eva

luat

ion

Gam

e/Si

ngin

g

Day

3

Song

Rev

iew

of p

revi

ous d

ay(1

0 m

inut

es)

Sess

ion

8 (c

ontin

ued)

: H

ome

visi

ting

and

the

use

of th

ePr

egna

ncy

Form

-Par

t I(1

hr 4

5 m

in)

TEA

Sess

ion

8 (c

ontin

ued)

: H

ome

visi

ting

and

the

use

of th

e P

regn

ancy

For

m P

art -

I (3

5 m

in)

Sess

ion

9: H

ome

visi

ting

and

the

use

of th

e Pr

egna

ncy

For

m -

Part

II(1

hr 1

0 m

in)

LUN

CH

Sess

ion

9 (c

ontin

ued)

: Hom

evi

sitin

g an

d th

e us

e of

the

Preg

nanc

y Fo

rm –

Par

t II

(1 h

r 30

min

)

TEA

Sess

ion

9 (c

ontin

ued)

: H

ome

visi

ting

and

the

use

of th

ePr

egna

ncy

form

–P

art I

I (3

5m

in)

Sess

ion

10: H

ow th

e C

HW

rela

tes

to t

he T

radi

tiona

l Bir

thA

tten

dant

(TBA

) (1

hr)

Eval

uatio

n (1

0 m

in)

Gam

e

Day

4

Song

Rev

iew

of p

revi

ous d

ay (1

0 m

in)

Sess

ion

11: F

ield

pra

ctic

e an

dus

e of

the

Preg

nanc

y Fo

rm(3

hrs

45

min

)To

pra

ctic

e pr

epar

ing

the

regi

ster

and

filli

ng in

the

Preg

nanc

y Fo

rm –

Par

ts I

and

II LUN

CH

Sess

ion

11 (c

ontin

ued)

:R

evie

w o

f fie

ld v

isit

and

prob

lem

sol

ving

(1 h

r 30

min

)

TEA

Sess

ion

12: Q

ualit

ies

of a

nid

eal C

HW

(1 h

r 15

min

)

Eva

luat

ion

Gam

e

Tim

e

0830

-103

0

1030

-104

510

45-1

230

1230

-140

014

00-1

530

1530

-154

515

45-1

700

1700

-173

0Ev

enin

g

Day

5

Song

Rev

iew

of p

revi

ous d

ay(1

0 m

in)

Mod

ule

3: T

reat

ing

Min

orA

ilm

ents

in th

e C

omm

un

ity

(Par

t I)

Sess

ion

1: C

lean

lines

s and

hand

was

hing

by

the

CH

W (

1 hr

)

Sess

ion

2: B

asic

Car

e of

Wou

nd a

ndSk

in P

robl

ems

(45

min

)

TEA

Sess

ion

2 (c

ontin

ued)

: Bas

ic C

are

ofW

ound

and

Ski

n P

robl

ems

(45

min

.)

Sess

ion

3: U

sing

asp

irin

and

para

ceta

mol

(1

hr)

LUN

CH

Sess

ion

3 (c

ontin

ued)

: U

sing

aspi

rin

and

para

ceta

mol

(15

min

)

Sum

mar

ise

Trai

ning

Wor

ksho

p 1

and

wha

t CH

W w

ill d

o in

the

com

mun

ity in

the

com

ing

mon

th(4

5 m

in)

Eval

uatio

n (1

5 m

in)

Clo

sing

(10

min

)



Module 1: Introduction to Newborn Health and Care

Session 1 : Traditional customs, beliefs and terminology in localcommunities surrounding childbirth and newborns

Day : 1Time Required : 1 hour and 15 minutes

Purpose

To allow CHWs who come from local communities to share their understanding of traditional customs

and beliefs during pregnancy, childbirth and infancy, and to identify the words used to describe these

events.

ObjectivesAt the end of the session the CHW will be able to:

1. Develop a glossary of local terms used during pregnancy, delivery and the neonatal (first month

after delivery) period.

2. Explain some of the local customs around childbearing, such as how the pregnancy is confirmed,

how the delivery is attended and conducted, rituals on giving clothes to the baby and beliefs about

initiating breastfeeding.

Materials Blackboard or white paper/flip chart paper (for small groups)

Markers

Notebooks and pens for each participant

Training Aid 1: Small Group Exercise

Preparation

Make one photocopy of the Training Aid 1

Cut the photocopy on dotted line to make three chits

Training MethodsGroup Discussion (10 minutes)

Instructions to Trainers :

Training Workshop 1Module 1 Introduction to Newborn Health and CareSession 1 Traditional customs, beliefs and terminologyTrainer Notes


1. Ask the group members why they think it is important to be aware of traditional beliefs and ritualssurrounding pregnancy, birth, and the first days of life. Why is it important to know the localwords used?

2. Listen to their answers and write the key answers on the blackboard. There are many correctanswers. The following are examples:

Knowing the community better will help the CHW work with the community more effectively to improvehealth.

Knowing local words means the CHW will have more effective communication with the community.This will decrease the gap between what women in the community mean and what the CHW perceives.

Knowing local practices will help the CHW determine if traditional practices should be praised andsupported, or, if harmful, more healthful practices should be suggested.

Small Group Discussion (20 minutes)

Instructions to Trainers :1. Divide the group into three groups by assigning each participant the number 1, 2 or 3. All the 1’s

join into a group, the 2’s into another group and the 3’s into a third group.2. Distribute the three chits made from training aid 1 to three groups, giving the task for Group 1 to

Group 1, the task for Group 2 to Group 2, and the task for Group 3 to Group 3.3. Explain the different tasks as follows: Group 1 will make two lists:

“Traditions during pregnancy” list and “Words used during pregnancy” list. This group will discusslocal customs surrounding pregnancy; for example, how pregnancy is discovered, what if anythingis done at that time, what traditions are followed during pregnancy about diet, work, havingsexual relations. When does a woman first declare her pregnancy to her family, to the outsideworld and to the TBA? These points are listed on the “Traditions during pregnancy” list. Whenspecial words are used (such as Inde: when a woman becomes pregnant while lactating her babyand before her period starts again), these words and the definitions are listed on the ‘Words usedduring pregnancy” list,

Group 2 will make two lists:“Traditions during delivery” list, and “Words used during delivery” list.This group will discuss local customs surrounding delivery; for example, how the communityknows when labour starts, when the TBA is called, what happens during delivery and the firsthours after delivery, what problems may arise, how they are treated, what is the TBA expectedto do. These points are listed on the “Traditions during delivery” list. When special words areused, (such as the word for the liquid that comes out when the bag of waters break), these wordsand the definitions are listed on the “Words used during delivery” list.

Training Workshop 1Module 1 Introduction to Newborn Health and Care

Session 1 Traditional customs, beliefs and terminologyTrainer Notes


Group 3 will make two lists:“Traditions during the neonatal period” list, and “Words used during the neonatal period “ list.This group will discuss local customs surrounding the newborn period; for example, how the babyis cared for after delivery, what is the first food the baby takes and when it is fed, traditionsaround breastfeeding (when and how often the baby is fed), how do they know if there isn’tenough milk? Are there rituals on giving clothes to baby? How do they know if something iswrong with the baby? These points are listed on the “Traditions during the neonatal period” list.When special words are used, these words and the definitions are listed on the “Words usedduring the neonatal period” list.

4. Allow 20 minutes for the small group work.

Group Discussion (30 minutes)

Instructions to Trainers :1. Have the group 1 present its lists. Discuss the findings in the larger group. Ask if anyone wants to

add or delete anything. Discuss and revise the lists.2. Continue as above with the group 2 and group 3. At the end of this exercise there should be

complete lists for all three groups.3. Ask the participants to start a ‘Glossary’ in their notebooks; the words used during Pregnancy,

Delivery and the Newborn period, should be noted in this glossary.

Summary (10 minutes)

Have a trainee summarise the main findings for customs during pregnancy; another trainee forfindings during delivery; and a third trainee for findings during the neonatal period.

Compliment the CHWs for their contributions.

The trainer evaluates his/her own session (5 minutes)

Objectives Assessment Method

Develop a glossary of local terms used Each trainee has a glossary of terms in herduring pregnancy, delivery and the notebook.neonatal period.

Explain some of the local customs around Each trainee has completed lists for customsduring childbearing, such as how the pregnancy, delivery and the neonatal period.pregnancy is confirmed, how the delivery isconducted and attended, rituals aroundfeeding the baby.

Training Workshop 1Module 1 Introduction to Newborn Health and CareSession 1 Traditional customs, beliefs and terminologyTrainer Notes


Small Group Exercise

(Cut on the serrated line and hand out each group’s tasks to the respective group.)

Group 1 will make two lists:

“Traditions during pregnancy” list and “Words used during pregnancy” list.

This group will discuss local customs surrounding pregnancy; for example, how pregnancy is discovered,what if anything is done at that time, what traditions are followed during pregnancy about diet, work,having sexual relations, etc. When does a woman first declare her pregnancy to her family, to the outsideworld and to the TBA? These points are listed on the “Traditions during pregnancy” list.

Under the “Words used during pregnancy” list, put any local words used during pregnancy and theirdefinitions. For example, Inde: when a woman becomes pregnant while lactating her baby and before herperiod starts again.


“Traditions during delivery” list, and “Words used during delivery” list.

This group will discuss local customs surrounding delivery; for example, how the family knows whenlabour starts, when the TBA is called, what happens during delivery and the first hours after delivery, whatproblems may arise, how they the problems treated, etc. What is the TBA expected to do? These points arelisted on the “Traditions during delivery” list.

When special words are used (such as the word for the liquid that comes out when the bag of watersbreak,), these words and the definitions are listed on the “Words used during delivery” list.


“Traditions during the neonatal period” list, and “Words used during the neonatal period” list.

This group will discuss local customs surrounding the neonatal period; for example, how the baby iscared for after delivery, what is the first food the baby takes and when it is fed, traditions aroundbreastfeeding (when and how often a baby is fed), how do they know there is enough milk. Are thererituals on giving clothes to baby? How do they know if something is wrong with the baby? These points arelisted on the “Traditions during the neonatal period” list.

When special words are used, these words and the definitions are listed on the “Words used duringthe neonatal period” list.


Module 1: Introduction to Newborn Health and Care

Session 2 : Introduction to home-based newborn care

Day : 1Time Required : 1 hour 20 minutes.

PurposeTo help CHWs understand that the newborn period constitutes an important time for mothers and

children in their communities. This leads to an introduction of the main objectives of the project. The CHWwill become acquainted with her new role and responsibilities and those of the people with whom she willbe working. The session concludes with an overview of the training schedule.


1. Explain why delivery and the baby’s first month of life are important for the health of mothers andbabies.

2. Explain the main objective of this project (reduction of newborn sickness and death in the firstmonth of life).

3. Describe, in general terms, the CHW’s role and the role of the trainer/supervisor i.e. neonatal caresupervisor (NCS) and vital statistics supervisor, (VSS), traditional birth attendant (TBA), surveyor,and community leaders.

Materials Blackboard or white paper/flip chart paper Markers Training Aid 1: Role and Responsibility Game sheets Training Aid 2: Visualisation Exercise

Preparation Make four sets of Training Aid 1 Cut the photocopies of the Role and Responsibility Game sheets (Training Aid 1) into strips (chits),

with each chit naming a task. Have at hand four boxes or bowls (to hold chits).

Training MethodsPresentation and Discussion (45 minutes)


1. Start with a story (see Content Box).

Training Workshop 1Module 1 Introduction to Newborn Health and CareSession 2 Introduction to Home -Based Newborn CareTrainer Notes


Content Box

Why newborn care is important to the community Tell this story : A woman I’m acquainted with, Shanti, was pregnant with her second child. She was

very happy. Her first child, a lovely boy, was already four years old. Shanti’s family was poor asothers in their village and she was thin. Although she wanted to do what she could to be stronger,the ANM wasn’t visiting the village and there was no other help to be had. When labour started,Shanti called the TBA. Although the TBA did what she could, when the baby was born it was smalland weak. Shanti’s mother-in-law fed the baby jaggery1 water. The baby got weaker and weaker,became cold, and died after three days. Shanti was very sad; she blamed herself and went into adepression. The whole family suffered. This story is not new. Do any of you know of a similar storyfrom your mohalla2? Have any babies died? Any mothers?·Trainer lets a few women tell their stories.This is a fact: Almost half of all deaths in children under five years occur during the newborn period.(Use a stick and break it in half to show that half of the babies die, or fill a jar with rice and saythese are all the children under five who die. Pour out half the rice; these children died in the firstmonth.)

Tell this story : Meerabai went into labour and called the TBA. She had a long labour and when thebaby was born it didn’t breathe for many minutes; there was no one to offer immediate assistance.Finally it took a weak breath. This baby lived but grew up mentally retarded and had fits. He wasnot able to live on his own and had to be taken care of by the family for the rest of his life. Everyonein the family was affected.Because the baby didn’t get treatment within minutes of being born, there was damage to his brainand he was not normal; those minutes changed the lives of many people.

Ask: What health care resources are available in your communities? Not much?Conclude that women and babies are very vulnerable around the time of delivery and the first month and there is little help availableAsk : What can be done?What actions could be taken for the baby in the first story that would have saved his life?The mother would have received health education during pregnancy by a Community Health Worker(CHW) so she would have eaten better and taken iron and folic tablets (antenatal care). She wouldhave been helped to breastfeed the baby right after delivery and would have been shown how tokeep the baby warm. The baby would have had medicine if needed.

2. Link the story to the need to develop a way to save newborn lives, to the background of home-based neonatal care and to the main project objectives. Use simple language to explain terms thatmay be unfamiliar.

3. For each of the following groups—CHWs, TBAs, trainers/supervisors (NCS, VSS), surveyors, ANMs,and community leaders—give a brief summary of what they do in the project and how they worktogether (See Content Box for the roles and responsibilities).

4. Briefly mention the schedule for training over the next 14 months.5. At the end of the presentation ask if there are any questions.


Session 2 Introduction to Home -Based Newborn CareTrainer Notes

1 Jaggery is a dark sugar made from cane 2 Mohalla is neighborhood


Training Workshop 1Module 1 Introduction to Newborn Health and CareSession 2 Introduction to Home -Based Newborn CareTrainer Notes

What actions could have been done for the baby in the 2nd story to prevent his brain damage?The CHW would have cleared the baby’s secretions, dried and stimulated him to help him breathesooner.

All these things could be done by a village worker. Let me tell you about SEARCH. SEARCH, an NGO in Gadchiroli district carried out a project in 39 villages, where Community Health

Workers (CHWs) were trained to care for newborn babies, in cooperation with the local TBA. The CHWsprovided health education to mothers during pregnancy, and gave immediate care to newborns at the time ofdelivery and for a month after birth. After a few years they counted how many newborn babies died in the firstmonth of life, and compared that number to the number of newborns who died in villages where no CHWsworked. In a area where 100 newborns used to die only 40 died with trained CHWs. The babies grew upbetter. Mothers in the villages give credit and respect to the CHWs.

Ask: Can we do a similar thing in our villages? A project, called ‘Ankur’ carried out the HBNC model in 7 locations in Maharashtra where local NGOs and

communities decided to do it. The main objectives of the project were:

- To learn from Gadchiroli villages and introduce similar care in our villages- To reduce the number of newborns becoming sick or dying in the first month of life.- To improve the health of mothers in the periods before and after delivery.- To reduce the number of children up to 5 years old sick and dying from pneumonia by giving

treatment. Roles and Responsibilities

CHW (at the end of training) performs following functions: General:

1. Provides health education to mothers and care to children2. Visits every house, making a list of all women who may get pregnant.3. Visits every two months all women who may get pregnant.4. Provides basic care for wounds, treats fevers and body aches in the community.5. Cares for children with cough and pneumonia.6. Keeps records and registers of each visit in the village, and of stock (supplies).

Pregnancy:7. Makes a list of pregnant women in the village.8. Visits all pregnant women in village and provides health education.9. Helps the supervisor organize a group talk for pregnant women every 4 months.

Delivery:10. Observes each mother in labor and delivery.11. Observes the baby right after delivery.12. Cares for the baby if it’s not breathing.13. Keeps baby warm after delivery.14. Helps the mother start breastfeeding.15. Examines the baby after the first hour.

After Delivery:16. Visits the mother and baby regularly in the first month after birth.17. Cares for the baby if baby is not gaining weight or is sick


Roles and Responsibilities (continued)

Keeps community leaders informed and involved by visiting them at least once in 6 monthsWhose help will you need to do this work?

Traditional Birth Attendant (TBA)1. Registers all births in the village.2. Cooperates with CHW and informs her when woman goes into labour.3. Practices clean and safe delivery.4. Attends women during labour and delivers baby5. Reinforces health education messages given by CHW.

Neonatal Care Supervisor (NCS)1. Trains the CHW.2. Helps the CHW obtain community cooperation.3. Visits villages to provide supportive supervision to the CHW.4. Reviews the CHW registers monthly and visits homes to check on information.5. Provides the CHW with supplies when needed6. Holds group health education sessions for pregnant women in every village she covers

Vital Statistics Supervisor (VSS) : Part time1. Co-trainer of CHW.2. Visits village once every six months to collect and check the data on births and

deaths (information collected by surveyor). Surveyor

1. Once every 6 months, visits house to house and collects birth and death informationabout children under five years of age.

Project Coordinator1. Guides the trainer/supervisors (NCS and VSS).2. Arranges for supply of medicines.3. Keeps dialogue with community leaders.4. Solves difficulties of the team.

Community Leaders support the project and can help if problems arise. Auxiliary Nurse Midwife gives tetanus toxoid (TT) injections, iron and folic tablets, and can

perform deliveries.

Training Schedule The training for HBNC is made up of seven training workshops, each lasting 3-5 days. It is

suggested that each training workshop be followed by at least one month of field practicebefore the next training workshop begins.

CHWs will learn something new each month in the sessions and then practice in their communitiesbefore the next training.

If the CHW encounters any difficulties these can be discussed and solved at the next training.


Session 2 Introduction to Home -Based Newborn CareTrainer Notes


Training Workshop 1Module 1 Introduction to Newborn Health and CareSession 2 Introduction to Home - Based Newborn CareTrainer Notes

Role and Responsibility Game for the Trainees (25 minutes)Instructions to Trainers :

1. Divide the trainees into four groups.2. Hand one set of chits to each group; the chits should be mixed up out of their original order.3. Give each group four boxes or bowls, one for each worker; CHW, TBA, VSS, NCS.4. Have the group read each chit, discuss which worker performs that task, and place it in the

appropriate bowl/box.5. Circulate around the room to assess level of understanding.


Ask a volunteer to explain why HBNC is important. Ask a volunteer to state the main project objectives. Ask a volunteer from group 1 to read the chits in the CHW bowl. Ask a volunteer from group 2 to read the chits in the NCS bowl. Ask a volunteer from group 3 to read the chits in the VSS bowl. Ask a volunteer from group 4 to read the chits in the TBA bowl. During the summary exercise, verify that each group has placed the same chit in the appropriate

bowl. If not, discuss and clarify the point. Reinforce the correct answers.



Explain why delivery and the baby’s first Questions and answersmonth of life are important times for thehealth of mothers and babies.

Explain the main objectives of this project. Questions and answers

Describe, in general terms, the role of the Role “Game” and “Summary.”CHW, NCS, VSS, TBA, surveyor andcommunity leaders.

Visualisation Exercise (40 minutes)

To be done in the evening session. See Training Aid 2.

Module 1 is Completed


Role and Responsibility Game

Note to trainer Cut each task (without the ‘CHW’ or ‘TBA’ attached) into a chit and mix them up. Give one set to each of the four groups. Have them place the right task in the bowl representing the worker responsible for doing that task. Allow 15 minutes for the activity. Allow 5 minutes for the summary.

CHW

Visits every house in village and records those homes with women may get pregnant.

Visits every two months, all women who may get pregnant.

Makes a list of all pregnant women in the village.

Visits all pregnant women in the village and provides health education.

Helps the Supervisor in organizing a talk for pregnant women, every 4 months.

Observes each mother in labour and delivery.

Observes the baby right after delivery.

Cares for the baby if the baby is not breathing.

Keeps the baby warm after delivery.

Helps the mother start breastfeeding.

Examines the baby after the first hour.

Visits the mother and baby regularly in the first month after birth.

If the baby’s weight has not reached 2.3 kg at the end of the first month, continues care for the babyin the second month.

Treats neonatal infection in the first month and also in the second month for high-risk babies.

Provides basic care for wounds, treats fever and body ache and cares for children with cough andpneumonia.

Keeps records and registers of each home visit in the village and of stock (supplies).

Meets key persons in the village once in six months to keep them informed.

TBA

Registers all births in the village.

Cooperates with the CHW and informs her when woman goes into labour.

Training Workshop 1Module 1 Session 2

Training Aid 1


Attends women during labour and delivers the baby.

Practices clean and safe delivery.

Reinforces health education messages given by the CHW.

NCS

Trains the CHW.

Helps the CHW cooperate with the community.

Visits villages to provide supportive supervision to CHW.

Reviews the CHW registers monthly and visits homes to check on information.

Provides the CHW with supplies when needed.

Provides group health education to pregnant women in each village under her care.

VSS

Helps NCS train the CHWs.

Visits the village once every six months to collect and check on information collected by the CHW.

Training Workshop 1Module 1 Session 2Training Aid 1



Training Aid 2

Visualisation Exercise

Lie down in your place, spreading your hands and legs……. Nothing should be bothering you…….Remove your spectacles…. If the mat is not comfortable adjust yourself. Spread your legs….. Hands are onsides. Palms facing the ceiling. Relax whole body….. Take a deep breath…. Exhale….. As you exhale yourbody relaxes…. Take a deep breath….. Exhale….. Each exhalation releases the tension. There is no burden….Mind is calm and quiet…….

Now concentrate on various parts of your body. Visit the part of the body that will be mentioned. Seeeach part with your mind. Pay attention to your right hand, its thumb, index finger next to it, third finger,fourth finger, little finger, whole right palm, right elbow, shoulder, relax all. Right shoulder, chest, rightside of abdomen, waist. Right hip joint, right thigh, knee, calf, ankle, foot, big toe, second toe, third toe,small toe.... complete right side…. Relax….. Now turn your attention to the left side of your body. Lefthand, thumb, index finger, third finger, fourth finger, little finger, whole left palm, elbow, shoulder, andrelax. Left shoulder, chest, left side of abdomen, waist, hip joint, left thigh, knee, calf, ankle, foot, great toe,second toe, third toe, fourth toe, small toe, complete left side…. Relax….

See the top of your head. Scalp, forehead, both eyebrows, eye lids….. there should be no tensionanywhere. Again see lids. Relax them. Nose, left cheek, right cheek, jaw, skull and jaw joint, relax…. Letyour mouth open. Upper lip, lower lip, relax the tongue…. Relax muscles of neck. See your back. See eachvertebra. Neck, back, vertebrae of waist, relax. Now the whole body is relaxed. There is no tension…….Only the respiration goes on. Concentrate on respiration. Respiration…… Inhalation…… Exhalation……..

Mind is calm and quiet…. No thought exists in mind. Now we are to travel in future by our mind. Youshall see the dream…. Go back to your village. In 3 years from now the home-based newborn care hasreached all villages. People know about it…. People are benefited by it. CHWs and TBAs are trained….You start in the morning for home visiting … It is eight in the morning…… filled with early sunshine……Birds are chirping. Cows are to go for grazing. Your saree is green, forehead decorated with kumkum. Abag on your shoulder. Bag carries the thermometer, weighing scale… now known to all.

People in the community know you and invite you, “Come and see our baby.” You turn towards thecall. On right side is a house with tiled roof. It is painted white. A woman is sitting near door. You haveearlier treated her baby. The baby is happily lying on a cot. Baby is three months old. Healthy baby.Properly wrapped in cloth. You have saved this baby. The mother offers you tea. Treats you with love andrespect. Says ‘Thanks’. You feel good. You are happy. You go to the next house. People in the housereceive and welcome you. They mention – ‘ you have saved our baby. The project has saved our baby.’People have gratitude for CHW and the project. They believe that home-based newborn care project cansave babies.

The village chief admires you. They admire you in presence of all villagers. They felicitate you.



Villagers tell everyone about the benefits of your work. You feel very happy. You are touched. Youthink…. ‘I have been able to help the community so much’.

You return home. You are tired after the whole day’s work… But you are satisfied. You lie down inbed. You thank God and sleep…….. Next day you are again in the village, and next day, still again.Children are being saved. Project is successful. You are successful. People are satisfied. You are honoredin the district. Your dream is coming true….. Really dream is becoming a reality….. Our project issuccessful…… Now no newborn will die……..

Once more, exhale deeply. Draw the right leg closer to your body. Draw the left leg…… Slowly getup and sit. Let the eyes remain closed. Put both the hands on your eyes. Rub your eyes gently. Slowlyopen your eyes. Open your eyes completely.


Module 2: Working in the Community andHome -Visiting During Pregnancy

Session 1: Working in the community


Purpose

To discuss who the CHW will be working for (target group) as well as identifying key persons in thecommunity, and the importance of good communication in reaching these groups.

Objectives

At the end of the session the CHW will be able to:

1. Explain what preparatory work has been carried out by the NGO to prepare for this project in thecommunity.

2. Explain the CHW target group.3. Mention three communication tips (use simple language, speak politely and kindly, listen, ask for

questions, etc.) useful when visiting mothers in their home to create a caring environment.

Materials

Training Aid 1: Model Role Play Script Handout 1 (HO-1): Communication Guide

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees. Make photocopies of Training Aid 1 for the use of trainers when they perform the scripted role

play.

Training MethodsPresentation (10 minutes)


1. Explain simply what the local NGO has been doing in the communities; including:


Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 1 Working in the communityTrainer Notes

NGOs have been working in each project village for some time and are expected to be collectinginformation on births and deaths.

NGO workers along with Trainer/Supervisors and the CHW have met with village leaders andobtained their cooperation for the HBNC.

Group Discussion (15 minutes)


1. Gather CHWs in a large circle.2. Ask who the CHW will be working for (target group).3. Ask the CHWs how they can establish rapport with village women. What is the best way to explain

their new role and get cooperation. What communication skills should they use?4. Encourage the CHWs to speak and be supportive.5. Listen to their answers and build on them (see Content Box below).6. Summarise main points.

Model Role Play by Trainers (35 minutes)

Instructions to Trainers :1. Distribute HO-1: the Communication Guide.2. Before starting the role play, ask trainees to review the Communication Guide. Trainees read each

point out loud. Discuss and clarify.3. Ask them to refer to the first part of the guide during the role play.4. After the role play, ask the trainees for feedback. Was anything left out? What could have been

better? What were the good points?5. In areas where performing a role play may be difficult (e.g., male trainers, tribal health workers),

read out the script loud as a story and then discuss.

Summary (5 minutes)

Ask a trainee to review what the NGO has done to prepare the community for HBNC. Ask CHWs who they will be working for (target group). Ask a trainee to explain how CHWs should talk to women in the community when visiting homes.

Basic Communication Skills

Start with a greeting. Be friendly. Speak clearly, using local language. Explain your new role and why you are visiting today. Be patient. Ask for any questions. Listen to the women.

Content Box


Make corrections if any and add missed information. Congratulate the CHWs for their good work.



Explain what preparatory work the NGO did Questions and answersin the community.

Explain the CHW target group. Group discussion. Question and answers

Mention three communication tips useful when Group discussiontalking to mothers. Question and answers

Training Workshop 1Module 2 Working in the Community and Home - Visiting During Pregnancy

Session 1 Working in the communityTrainer Notes


Model Role Play Script

Total time: 10 minutesIntroduce the characters and scene to the CHWs: A village woman, Sheelabai, and CHW, Sangeetabai,

meet and try to understand each other.

CHW: Local Greeting (where appropriate). What are you doing Sheelabai?

SH: Who is there? Sangeetabai?

CHW: Why are you sitting? Is your work over?

SH: How come you are here this time?

CHW: I had some work with you.

SH: Oh! I come to know that you are working as a CHW. Is it true? What is it?

CHW: One social service organization in our region has selected me as a CHW to work in the field ofhealth.

SH: Does this mean you will take care of all our health?

CHW: No, No.

SH: Then what are you going to do?

CHW: Have you heard that Meena’s baby died right after delivery about 2 months back?

SH: Yes, I know.

CHW: Has that happened to anyone in your mohalla?

SH: Not to me, but to my sister-in-law about a year ago and to my cousin’s wife last month.

CHW: You see, this is not unusual. Women and babies are more vulnerable before and after delivery andsomething should be done to make sure they have a better chance at living.

SH: Yes, you’re right. What can we do?

CHW: Well, that’s why I’m here. I am being trained to take care of babies at the time of delivery and untilthe baby is a month old. I am going house to house to make a list of all women who may getpregnant, like you. Every two months I will visit all of you. If anyone becomes pregnant I will visitthem during pregnancy. The TBA will call me to the delivery, and while she cares for the motherI will care for the baby. Because I am in training now, I am learning a little at a time. After somemonths I will have enough training and experience to care for babies during and after delivery,but I already can treat minor wounds if anyone in the village needs help, and soon I’ll be able todispense aspirin and paracetamol for fever and body aches.

SH: When are you going to start your work?

CHW: From today only.



SH: Then what exactly is your work with me today?

CHW: I need to know how many women of childbearing age live in this house and if anyone is pregnant.Then I have to prepare a list of pregnant women, as I will be visiting them during their pregnancy.For that only I have come to you.

SH: Then write my name. I am the only woman here of childbearing age as my mother is old.

CHW: Yes. I will write your name. (Writes Sheelabai’s name.) Now I will visit you every two months.

SH: Ok. No problem .

CHW: Ok then. Bye. We shall meet again.


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Training Workshop 1Module 2 Session 1HO 1


Module 2: Working in the Community andHome - Visiting During Pregnancy

Session 2: Talking with women in the community (practice)

Day : 1Time Required : 1 hour

Purpose

To provide an opportunity for CHWs to practice basic communication skills needed to build a cooperativerelationship with women in the community and to experience various situations they may have to facewhile visiting homes.


1. Demonstrate basic communication skills when talking to mothers.2. Demonstrate how to handle women who are shy, argumentative, inquisitive, and not friendly.

Materials Communication Guide (HO-1) from Module 2 Session 1

Preparation Prepare four role-play scenarios which include a woman who is shy, argumentative, inquisitive,

and not friendly. Make one copy of each role play to distribute to the small groups. Alternatively,you can ask the trainees to make up their own role plays.

Instruct the trainees in advance to bring their copies of the Communication Guide which wasdistributed in the previous session (Module 2 Session 1 Handout1).

Training MethodsRole Play in Small Groups (1 hour)


1. Divide the trainees into groups of four.2. Give each group a role play scenario (woman is shy, argumentative, inquisitive and not friendly).3. Allow each group ten minutes for thinking how to present the role play, and for practicing.


Session 2 Talking with Community Women (practice)Trainer Notes


Content Box

Communication PointsCHW Greets, is friendly Explains new role Explains why she is visiting today Speaks in gentle tone of voice Uses simple words in local language Asks for questions Answers simply Is kind Acts with confidence

If the woman is shy CHW should Speak of general things to ‘warm her up’ Encourage the woman to speak Praise the woman to give her confidence Repeat the question

If the woman is argumentative CHW should Praise the woman Sympathise with her Not push if the woman is still not receptive. Try next time.

If the woman is inquisitive CHW should Answer her questions simply Explain she will be coming in two months so they can talk

again

If the woman is not friendly CHW should Listen to the woman Be friendly Praise her Explain that she is there to help Not push; say she would like to come again

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 2 Talking with community Women (practice)Trainer Notes

4. Allow each group five minutes to present the role play while the trainers and other trainees use therole play checklist.

5. Follow each role play with discussion and suggestions (5 minutes).6. Praise CHWs for their correct practice and suggestions, and summarize basic communication points

(see Content Box below).



Session 2 Talking with Community Women (practice)Trainer Notes

The trainer evaluates his/her own session (while observing the role plays duringsession)


Demonstrate basic communication Observation of role play;skills when talking to mothers. use checklist during observation.

Demonstrate how to handle women Observation of role play;who are shy, argumentative, inquisitive, use checklist during observation.and not friendly.



Session 3: Preparing the list of all women in the village who may getpregnant

Day : 1Time Required : 1 hour 15 minutes

Purpose

To instruct CHWs on how to correctly record the list of all women in the village who may get pregnant.

Objective


1. Complete the ‘List of all women in the village who may get pregnant’ in the record sheet correctly.

Materials

Handout 1 (HO-1): List of all women in the village who may get pregnant

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees.

Training Methods

Presentation and Demonstration (20 minutes)


1. Define ‘women who may get pregnant’:

o Married women between the time they start their menses until they stop (menopause) dueto old age may get pregnant.

o If women or their husbands have been operated upon (sterilized) such women are notincluded in the list as they cannot become pregnant.

1 An unmarried pregnant woman will not be included in the ‘List of all women who may get pregnant’ due to culturalconsiderations in rural India. She should however be included in the ‘List of pregnant women’ and will receive HBNC services.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 3 Preparing the list of all women in the village who may get pregnantTrainer Notes


Session 3 Preparing the list of all women in the village who may get pregnantTrainer Notes


o Women who are widowed, separated, or unmarried are not on the list.o If an unmarried woman is obviously pregnant, her name will not be included in the ‘List

of women who may get pregnant’1 but will be included in the ‘List of pregnant women’ if sheis willing.(see session 7).

2. Explain that you do not put a visitor’s name on this list, even if she satisfies all the criteria. 3. Go through each question in the record sheet and explain how to fill it out while trainees follow

along by reviewing the practice sheet.4. Ask for any questions and clarify any confusion.

Practice (55 minutes)


1. Have each trainee interview at least 10 of the other trainees and record the information on thepractice sheet.

2. Circulate in the room and assist as needed.3. At the end of the practice, ask for any questions or comments.

Summary

Ask a trainee to define a ‘Woman who may get pregnant’. Ask trainees to list information they will collect from women for the record : ‘List of the women in the village who may get pregnant’ Make corrections if any and add missed information. Congratulate the CHWs for their good work.

The trainer evaluates his/her own session (during session)

Objective Assessment Method

Complete the ‘List of all women in the Each trainee correctly completes thevillage who may get pregnant’ in the record : ‘List of all women in the villagerecord sheet correctly. who may get pregnant’.


Session 3 Preparing the list of all women in the village who may get pregnantTrainer Notes


Ask the following questions:1. Have your periods stopped?2. Do you stay with your husband?3. Are you operated upon for family planning?4. Is your husband operated upon for family planning?

List of all women in the village who may get pregnant

Sr. No Name of the woman Age Subsequent Changes Date ofrecording the name

Training Workshop 1Module 2 Session 3HO-1



Session 4: Preparing the register book to record the list of all women inthe village who may get pregnant

Day : 2Time Required : 55 minutes

Purpose

To prepare the pages in the register book for the ‘List of women who may get pregnant’ and toreinforce the information required when interviewing women.

Objective

At the end of the session the CHW will be able to:1. Prepare the ‘List of women who may get pregnant’ pages in her register book.

Materials

Register books for each trainee (20) Completely prepared register book (as a model) Ruler, pens ‘List of all women in the village who may get pregnant’ practice sheets to use as a model (Module

2 Session 3 HO-1)

Preparation Prepare a completed register book (as a model). Instruct the trainees in advance to bring the list of women who may get pregnant practice sheets

which they completed in the previous session (Module 2 Session 3).

Training Methods



1. Distribute the register books and guide CHWs to the pages they will use to draw the columns androws needed.


Session 4 Preparing the register book to record the list of all women in the village who may get pregnantTrainer Notes


2. Show a register book with the ‘List of all women who may get pregnant’ pages drawn correctly.3. Ask the trainees to write the following points on the first page of the register book. Questions to be asked:

o Are you getting your monthly periods?o Are you living with your husband?o Have you had a family planning operation?o Has your husband had a family planning operation?

4. Move around the room answering questions and giving help as needed.

The trainer evaluates his/her own session (10 minutes)Objective Assessment Method

Prepare the format for ‘List of all Review the format for ‘List of all womenwomen in the village who may get in the village who may get pregnant’pregnant’ pages in her register book. prepared in her register book.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 4 Preparing the register book to record the list of all women in the village who may get pregnantTrainer Notes


Session 4 Preparing the register book to record the list of all women in the village who may get pregnantTrainer Notes



Session 5: Determining the date of last menstrual period (LMP)

Day : 2Time required : 1 hour 45 minutes

Purpose

To train CHWs to determine the date of a woman’s last menstrual period (LMP) by discussion with women‘who may get pregnant’ during the home visit.

Objective


1. Determine the LMP of women ‘who may get pregnant’.

Materials

Training Aid 1: Model role play script : Determining LMP Calendar with indication of festivals (to be prepared locally) Special event sheet prepared by NGO indicating dates of special events in the local region Communication Guide (Module 2 Session 1 HO-1) Box 1 and 3 Handout 1: The circle aid for determining LMP (to paste in the register book)

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees. Prepare the festival calendar and the special event sheet mentioned under Materials above and

make copies equal to the number of trainees for distributing one to each trainee. Prepare for the role play. Prepare four scenarios: to portray a CHW visiting different women—one who is 3 months pregnant,

another 5 months pregnant, 7 months pregnant, and 8 months pregnant. Instruct the trainees in advance to bring their Communication Guide (Module 2 Session 1

Handout 1).


Session 5 Determining the date of last menstrual period (LMP)Trainer Notes


Training MethodsModel Role Play (30 minutes)

Instructions to Trainers :1. Review and discuss the Communication Guide (boxes 1 and 3) with the trainees.2. Explain that you (and another trainer or a volunteer) will be performing a role play showing a return visit

to a woman who may get pregnant. Using Training Aid 1: Model role play script, perform the scriptedrole play.

3. Afterwards, discuss the role play and ask the trainees what they observed (refer to communicationguide if needed). How did the CHW ask questions? Did she make the woman feel comfortable? etc.

4. Make sure the trainees mention how the woman was questioned to get the LMP.

Role Plays in Small Groups (1 hour 15 minutes)

Instructions to Trainers :1. Divide trainees into four groups.2. Each group has a different scenario; one portrays a CHW visiting a woman 3 months pregnant,

another 5 months pregnant, 7 months pregnant, and 8 months pregnant.3. Have the groups work out their woman’s LMP and perform a role play showing how the CHW

determined the date.4. During the presentations, use the Communication Guide boxes 1 and 3.5. Lead a discussion after each presentation. Were good communication skills used? Was the LMP

determined correctly?6. Make sure that the LMP is determined correctly in each presentation. Give supportive feedback on

communication skills used.

Summary

Ask a trainee to describe some good communications skills. Ask trainees how to determine a woman’s LMP. Make corrections if any and add missed information. Congratulate the CHWs for their good work.

The trainer evaluates his/her own session (during session by observing role plays)


Determine the LMP of women ‘who may Observe role plays, using the communicationget pregnant’. guide, to check if trainees can determine

LMPs of women ‘who may get pregnant’.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 5 Determining the date of last menstrual period (LMP)Trainer Notes


Model Role Play Script : Determining LMP

Total time: 15 minutes

Introduce the characters and scene to the trainees: The name of the CHW is Vimal; the name of the

woman is Shanta. The CHW makes a home visit to Shanta and helps determine her LMP.

Vimal: (Knocks on the door and calls out) Is anybody home? Shanta, are you home?

Shanta: (Opens the door) Oh! Is it Vimal? What a surprise! How come you visit at this hour?

Vimal: You know, I am visiting all homes where women are of the age to get pregnant and seeing if

anyone is pregnant.

Shanta: Oh! But what use will it be?

Vimal: Part of my job is to make a list of pregnant women so that in future, I will visit and help them.

Shanta: Oh! I am really relieved! I was so anxious….

Vimal: So, there appears to be some development….

Shanta: I am not sure. I think I may be pregnant because I haven’t had my menstrual period since last

many days.

Vimal: Let’s see. Can you tell me when you had your monthly bleeding? Can you tell me the date of the

first day?

Shanta: I can’t tell you the date.

Vimal: Maybe you don’t remember the date, but can you tell me whether there was any important

festival or some important event close to the day on which you started?

Shanta: Let me think. Yes, it ended when Dashera1 started.

Vimal: Well that helps me! (CHW looks at the calendar and finds the date on which Dashera started.) How long

does your monthly bleeding last?

Shanta: My period lasts about 5 days.

Vimal: You see (points to the calendar) , Dashera was on 26th Oct. Five days before that is

21st Oct. It looks like the first day of your last period was 21st Oct. Is not that so?

1 Dashera is an Indian festival.


Training Aid 1


Shanta: I really can’t say anything about the date. I have confidence in you and you looked up the date

in the calendar, so that must be right.

Vimal: Today is 2nd January so it is likely that you are pregnant.

Shanta: Are you sure? Is my pregnancy confirmed?

Vimal: I can’t confirm it but it appears most likely. Sometimes monthly bleeding gets delayed due to

some other reasons also. We will probably be able to confirm it during my next visit after two

months.

Shanta: Please come. In the meanwhile if I have something to tell you I will meet you and tell you.

Vimal: Of course! You are welcome to visit me. Otherwise I will visit again in two months.



The Circle Aid for Determining LMP

To help health workers count days before or after a particular day while determining LMP


HO-1

1 23

4

5

6

7

8

9

10

11

12

13

14151617

18

19

20

21

22

23

24

25

26

27

28

2930



Session 6: Determining the expected date of delivery (EDD)


Purpose

To explain how the expected date of delivery (EDD) is determined and to provide trainees practice indetermining EDD though exercises.

Objective

At the end of session the CHW will be able to:

1. Determine a woman’s EDD based on her LMP.

Materials

Handout 1 (HO-1): The chart to determine EDD and preterm based on the LMP Handout 2 (HO-2): The measuring strip to determine change in year (to paste in register book) Handout 3 (HO-3): EDD worksheet Training Aid 1: Answers to EDD worksheet HO-3

Preparation

Make adequate photocopies of Handout 1, 2, and 3 depending on the number of trainees. Get thephotocopy of the handout 3 laminated before distributing the copy among the CHWs, which can thenbe used for a longer period without spoiling it.

Training Methods

Presentation (45 minutes)


1. Explain EDD with formula (see Content Box).2. Demonstrate how you determined EDD in the three examples.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 6 Determining the expected date of delivery (EDD)Trainer Notes


Content Box

Determining EDD

EDD = LMP + 7 days + 9 months

Give examples: LMP: 10th Dec. 2005 EDD: 17 Sept.2006

LMP: 28th Sept. 2005 EDD: 4 July 2006

LMP: 2nd Nov. 2005 EDD: 9 August 2006

Note: This method gives an approximate date of delivery, and a baby may be born 15 days beforeor after.

Note: If a woman has not had her period since her previous delivery, and she is pregnant, theCHW will not be able to determine the LMP or EDD. This is called ‘Inde’ in the Gadchiroli districtin India.

3. Distribute HO-1: The chart to determine EDD and preterm based on the LMP. This chart can also beused to determine EDD. Explain how to use this chart. The chart shows each of the 12 months. Each of the 12 months has 3 columns; LMP, EDD

and Preterm cutoff date. For each month, the top line (LMP line) shows each day of the month (i.e., January 1, 2, 3) from

left to right. For example, if the LMP is 10 December 2005, you locate this by going to December, finding

the LMP line (top one) and moving from left to right until you reach number 10. From here, tofind the EDD simply look at the column below (EDD line). (EDD = 16 September).

Note: When using the formula (EDD = LMP + 7 days +9 months), the EDD comes to17 September. This slight variation is because the formula is less accurate than the chart becausethe chart takes into account longer and shorter months. Use the chart for accuracy, but if thechart is lost or not available you can use the formula.

4. Distribute HO-2: the Measuring Strip to determine change in year. Explain and demonstrate how touse this strip. The numbers on top represent the months of the year. The first 12 months are in one year (2005)

and the next 12 months are in the next year (2006). Using the example above, if the LMP is in December 2005, that would be the box under ‘12’ in

2005. To find the EDD, move to the right 9 months, which brings you to September of the nextyear (2006).


Session 6 Determining the expected date of delivery (EDD)Trainer Notes




1. Give an EDD worksheet (HO-3) to each trainee. In the space opposite the LMP, ask them to determinethe EDD (they should practice with HO-1 The chart to determine EDD and preterm based on theLMP). Use Training Aid 1 as a reference.

2. Have each trainee present one example and explain how she determined the EDD.3. Praise the CHWs who have answered correctly and help those who did not.4. Clarify any misconceptions.

Evaluation (10 minutes)

Quick quiz: Give each trainee three LMP dates and ask for corresponding EDD (using the chart todetermine LMP-EDD).

1. LMP 30 January 2006 EDD? (answer: 6 November 2006)2. LMP 15 December 2005 EDD? (answer: 21 September 2006)3. LMP 30 April 2005 EDD? (answer: 4 February 2006)


Determine EDD. Each trainee identifies correctly twoout of three EDDs in the quick quiz.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 6 Determining the expected date of delivery (EDD)Trainer Notes



HO-1





HO-1


The Measuring Strip to Determine Change in Year


1 2 3 4 5 6 7 8 9 10 11 12 1 2 3 4 5 6 7 8 9 10 11 12

2005 2006


EDD Worksheet

LMP EDD11 July 2003

1 December 2003

27 October 2004

1 July 2004

7 November 2004

14 June 2004

30 November 2004

23 March 2004

2 February 2004

26 January 2004

15 August 2003

20 January 2004

4 May 2003

3 April 2004

29 February 2004

1 January 2005

30 April 2005

31 March 2004

4 September 2004


HO-3


Answers to EDD Worksheet (HO-3)

LMP EDD

11 July 2003 17 April 2004

1 December 2003 7 September 2004

27 October 2004 3 August 2005

1 July 2004 7 April 2005

7 November 2004 14 August 2005

14 June 2004 21 March 2005

30 November 2004 6 September 2005

23 March 2004 28 December 2004

2 February 2004 9 November 2004

26 January 2004 2 November 2004

15 August 2003 22 May 2004

20 January 2004 27 October 2004

4 May 2003 9 February 2004

3 April 2004 8 January 2005

29 February 2004 7 December 2004

1 January 2005 8 October 2005

30 April 2005 4 February 2006

31 March 2004 5 January 2005

4 September 2004 11 June 2005

Training Workshop 1Module 2 Session 6Training Aid-1



Session 7: Preparing the list of pregnant women


Purpose

To show the CHW how to prepare the ‘List of pregnant women’ and to provide time for her topractice.

Objective

At the end of the session CHWs will be able to:

1. State how to prepare the ‘List of pregnant women’ by visiting the women in the ‘List of all womenin the village who may get pregnant’.

Materials

‘List of all women in the village who may get pregnant’ record sheet (Module 2 Session 3 HO-1) Handout 1 (HO-1): ‘List of pregnant women’ record sheet.

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees. Instruct the trainees in advance to bring their copies of the ‘List of all women in the village who

may get pregnant’ record sheet (Module 2 Session 3 HO-1) (when they interviewed each other). Prepare an example of a ‘List of all women in the village who may get pregnant’ and write in 3-4

pregnant women.

Training MethodsDemonstration (30 minutes)


1. Display the full record sheet and explain each column of the record sheet.2. Using the example of a ‘List of all women in the village who may get pregnant’, they have prepared,

explain the trainees that they are supposed to visit these homes and find out whether any one from


Session 7 Preparing the ‘List of pregnant women’Trainer Notes


the ‘List of all women in the village who may get pregnant’ is presently pregnant. If yes findout LMP with her help, and write her name in the list of pregnant women if she has completed4 months of pregnancy. .

3. Explain the following: Note that when working in the community, a CHW should register pregnant women

by 4 or 5 months; the exception would be the first month after training when they arefirst making up the lists.

If a pregnant woman from outside the village comes to deliver in the village, add her tothe list of pregnant women. Do not add her name to the list of all women in the villagewho may get pregnant, since she will not be staying in the village after delivery.

If an unmarried woman is pregnant and wants to be visited, add her name to the List ofPregnant Women and start visiting her.


Instructions to Trainers :1. Ask the trainees to take out their ‘List of all women in the village who may get pregnant’

from session 3 (when they interviewed each other).2. Instruct them to make up an LMP for three women on the list and pretend they are pregnant

(this is likely to cause laughs as the list is composed of CHWs!).3. Have trainees make the ‘List of pregnant women’ using information from the ‘List of women

who may get pregnant’.4. Review all ‘Lists of pregnant women’ and clarify difficulties.

Summary

Ask a trainee to state when they should register pregnant women (the latest months). Ask a trainee to list the information that will be collected from a pregnant woman on the List of

pregnant women. Make corrections if any and add missed information. Appreciate the CHWs for their good work.



State how to prepare the List of Questions and answerspregnant women by visiting the women in‘List of all women in the village whomay get pregnant.’

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 7 Preparing the ‘List of pregnant women’Trainer Notes


Lis

t of

Pre

gnan

t W

omen

Sr.N

o

Nam

e of

wom

anV

illa

geA

geLM

PE

DD

Dat

eS

exN

ame

of th

eR

emar

kof

del

iver

yof

bab

yvi

llag

e w

her

e(e

g. h

osp

ital

/hom

ed

eliv

ered

del

iver

y)


HO-1



Session 8: Home visiting and use of the Pregnancy Form - Part I

Day : 2 and 3Time Required : 3 hours 15 minutes

Purpose

To introduce the CHW to new terms and their meaning so that she will be able to complete Part I ofthe Pregnancy Form.

Objectives


1. Determine the number of past pregnancies a woman had and their outcomes.2. Define abortion, stillbirth, neonatal death, and Inde1.3. Complete Part I of the Pregnancy Form.

Materials Handout 1 (HO-1): Pregnancy Form – Part I Handout 2 (HO-2): Excercises to determine ‘abortion’, ‘stillbirth’, or ‘neonatal death’ Training Aid 1: Answers to excercises of HO-2 Handout 3 (HO-3): Worksheet to determine number of pregnancies and births Blackboard or white paper/flip chart paper Markers

Preparation Make adequate photocopies of Handout 1, 2 and 3 depending on the number of trainees.

Training MethodsPresentation (45 minutes)

Instructions to Trainers :1. Distribute HO-1 the Pregnancy Form – Part I. Go through each question in Part I (questions 1-7),

explaining unfamiliar terms (see Content Box).

1 Inde is a term used in India for women who get pregnant without having resumed their menses after a previous delivery.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 8 Home visiting and use of the Pregnancy Form - Part ITrainer Notes


2. Explain how to use the form to determine total number of pregnancies and delivery outcomes(question 7).

3. Ask for questions and clarify as needed.4. Explain the following:

Part I of the Pregnancy Form can be completed when the pregnancy is confirmed (during thehome visit every two months), or after completing the fourth month of pregnancy (in the 5th

month). In total, four visits should be made during pregnancy: in the 5th month (registration), in the 7th

month, 8th month and 9th month. In the initial stages, before the intervention starts, only threevisits are made: during the 5th, 8th, and 9th month. After intervention begins, four visits will bemade, (as above). During the visits, the form will be completed and appropriate health educationgiven.

In India, up to 50% of pregnant women in rural areas return to their parent’s village for thedelivery. It is important that these women and their newborns receive care too.

If a pregnant woman comes to the village in the 8th month of pregnancy, visit her, register her,provide health education, and screen her for problems. Fill the Pregnancy Form (Part I and the8th month screening in Part II). Visit the woman again in the 9th month to complete the screening(Part II) and provide health education on preparing for delivery. (Health education shouldonly be started after the CHW learns to give health education in Module 12.)

Gestation: The duration of pregnancy. Abortion: If the foetus dies before 6 months and 15 days of gestation. An abortion can occur

naturally (miscarriage) or it can be performed by a medical person (Medical Termination ofPregnancy -MTP). Sometimes unqualified people also perform abortions (this is dangerous).

Stillbirth: Baby (more than 6 months and 15 days gestation) is born without any sign of life1 ie.breathing, crying or moving limbs; and hence, is dead at birth.1. Fresh Stillbirth: Baby looks normal but is not alive. A fresh stillbirth means the baby died

inside the mother recently.2. Macerated Stillbirth: Baby does not look normal; skin is falling off and is decaying. In a

macerated stillbirth the baby died inside the mother some time ago. Live Births: Baby (born after more than 6 months and 15 days gestation) shows any one of the

signs of life1 at birth (even briefly): breath, cry or movement of limbs. Neonatal Death: If a baby (with the gestation more than 6 months and 15 days) born alive dies

between birth and 28 days of life. Even if the baby only breathes once and then dies, it is still aneonatal death.

Pregnancy occurs without resuming monthly bleeding (Inde): A woman becomes pregnantbefore she resumes her monthly bleeding after her last delivery.

Content Box


Session 8 Home visiting and use of the Pregnancy Form - Part ITrainer Notes

1 Other signs of life include heart beating and umbilical pulsation. These have not been included in the definitionhere because CHWs may find these signs difficult to recognise.


If a woman only comes to the village in the 9th month, register her, provide health education,and screen her for problems. If possible, visit her two times in the 9th month to reinforce thehealth education messages.

If a woman delivers outside the village and returns to the village within 28 days, visit her, askher about her pregnancy and delivery, and complete the Pregnancy Form.

Practice: Determining abortion, stillbirth, live birth or neonatal death (1 hour)


1. Draw a ‘time line’ (as in the exercises) on the blackboard or flip chart paper and explain where onthe timeline abortion, stillbirth, live birth and neonatal death take place. If there is confusion, trydrawing a decision tree as follows:

2. Distribute HO-2 the exercise sheet to each trainee.3. Have them work individually (or in a small group of no more than three) to determine if the baby

who died was an abortion, stillbirth or neonatal death.4. After each scenario, have them mark an ‘x’ on the timeline where the death occurred, and write

whether it was an abortion, stillbirth or neonatal death.5. After the exercise, have trainee volunteers present each scenario; on the blackboard draw the timeline,

mark an ‘x’ where the death occurred and say whether it was an abortion, stillbirth or neonataldeath.

6. Ask for questions and clarify. Use the Training Aid 1 (Answers to HO-2) for reference.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 8 Home visiting and use of the Pregnancy Form - Part ITrainer Notes

Before After


Demonstration/Practice: Determining total number of pregnancies and births (30 minutes)

Instructions to Trainers :1. Have trainees look at question 7 of the Pregnancy Form. Discuss how to use the form for determining

total number of pregnancies and birth outcomes.2. Distribute HO-3: Worksheet to determine number of pregnancies and births. Explain that the

worksheet contains five copies of question 7; use one copy for each interview.3. Working in pairs, have each trainee interview another trainee to find out how many pregnancies

and births she has had. Complete the first box of questions.4. Have trainees change partners and interview four other trainees (total of five) to determine how

many pregnancies and births they have had.5. Observe and assist as needed.

Practice: Filling in the Pregnancy Form Part I (1 hour)


1. Make sure each trainee has five copies of Part I of the Pregnancy Form.2. Working in pairs, have each trainee interview her partner and complete Part I of the Form. Allow

5-10 minutes for each interview.3. Have trainees change partners to complete at least five interviews.4. Observe and help when needed.


Ask a trainee to define abortion, another trainee to define fresh stillbirth, another macerated stillbirth,etc. until all new terms are defined.

Make corrections if any and add missed information. Congratulate the CHWs for their good work



Determine pregnancies, and delivery Practice exercise HO-3.outcome by interviewing mother.

Define abortion, stillbirth, neonatal death, Timeline exercise HO-2and “Inde”. Observe interviewing

Complete Part I of Pregnancy Form. Observe interviewingReview Pregnancy Form Part I


Session 8 Home visiting and use of the Pregnancy Form - Part ITrainer Notes


Pregnancy Form: Information of the pregnant woman (mother)

Part I

1) Date of filling in the form 2) Age of mother (full years)

3) Mother’s full name

4) Place of usual residence of mother Taluka

5) Education (Mother’s)

Education (Husband’s)

6) LMP Date Month Year / INDE

7) Ask the pregnant mother the following information:

History of previous pregnancies.

Sr. No ofPregnancy 1 2 3 4 5 6 7 8 9 10

Completedgestationperiod atthe time ofdelivery

Abortion Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No

Stillbirth Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/NoPreviousneonatal Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/No Yes/Nodeath



Exercises to Determine Abortion, Stillbirth, and Neonatal Death

After each story, put an ‘x’ on the timeline showing when the baby died and write whether it was anabortion, stillbirth, or neonatal death.

Case:

1. After 9 months of pregnancy, Meera delivered a baby girl who died after two weeks.

Pregnancy starts 6 months 15 days Birth 28 days

* * * X *

Neonatal death

2. Jeena got pregnant in June and lost the pregnancy in August.


* * * *

3. Geeta was pregnant for 7 months when she started labour pains. The baby was born butdidn’t breathe, cry or move its limbs.


* * * *

4. Neeta got pregnant but started bleeding at 6 months and lost the baby.


* * * *


HO-2


Answers to Exercises to Determine Abortion, Stillbirth, and Neonatal Death(Handout –2)

After each story, put an ‘x’ on the timeline showing when the baby died and write whether it was anabortion, stillbirth, or neonatal death.

Case:1. After 9 months of pregnancy, Meera delivered a baby girl who died after two weeks.


* * * X *

Neonatal death

2. Jeena got pregnant in June and lost the pregnancy in August.


* X * * *

Abortion

3. Geeta was pregnant for 7 months when she started labour pains. The baby was born butdidn’t breathe, cry or move its limbs.


* * X * *

Stillbirth

4. Neeta got pregnant but started bleeding at 6 months and lost the baby.


* X * * *

Abortion



Worksheet to Determine the Number of Pregnancies and Births

Interview 1:

Number of 1 2 3 4 5 6 7 8 9 10PregnanciesCompletedgestationperiod at thetime ofdelivery

Abortion Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/No No No No No No No No No No

Stillbirth Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/No No No No No No No No No No

Previous Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/neonatal No No No No No No No No No Nodeath

Interview 2:

Number of 1 2 3 4 5 6 7 8 9 10Pregnancies

Completedgestationperiod at thetime ofdelivery





HO-3


Interview 3:

Number of 1 2 3 4 5 6 7 8 9 10PregnanciesCompletedgestationperiod at theat time ofdelivery




Interview 4:

Number of 1 2 3 4 5 6 7 8 9 10PregnanciesCompletedgestationperiod at thetime ofdeliveryAbortion Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/

No No No No No No No No No NoStillbirth Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/

No No No No No No No No No NoPrevious Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/neonatal No No No No No No No No No Nodeath



Interview 5:

Number of 1 2 3 4 5 6 7 8 9 10PregnanciesCompletedgestationperiod at thetime ofdeliveryAbortion Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/




HO-3



Session 9: Home visiting and use of the Pregnancy Form - Part II

Day : 3Time Required : 3 hours and 15 minutes

Purpose

To enable the CHW to make home visits during pregnancy, to screen the pregnant woman for certainhealth problems, and to record the details and complete Part II of the Pregnancy Form.


1. Explain the timing of the CHW visits to the pregnant woman during pregnancy.2. Give the correct definitions for the terms listed in the Content Box.3. Complete Part II of the Pregnancy Form (8th and 9th month) correctly.

Materials Handout 1 (HO-1): Pregnancy Form – Part II Handout 2 (HO-2): Photograph of a woman with swollen face and hands with indentations Handout 3 (HO-3): Case Presentation Model Role Play - Visiting mother at 8 months and 9 months (to be made up on the spot by trainers)

Preparation Make adequate photocopies of Handouts 1, 2, and 3 depending on the number of trainees.

Training MethodsPresentation and Discussion (1 hour)

Instructions to Trainers :1. Distribute HO-1: Part II of the Pregnancy Form.2. Explain how the columns are divided to record information from the visit at 8 months and the visit

at 9 months.3. Explain the following:

That at both 8 and 9 months the same questions will be asked. If a pregnant woman comes in the village in the 8th or 9th month of pregnancy, visit her

and fill the Pregnancy Form completely.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 9 Home visiting and use of the Pregnancy Form - Part IITrainer Notes


If she comes in the 8th month she should be visited in the 8th month. Part II should be completedat the time of the first visit and again in the 9th month.

If a woman comes in the 9th month, Part II should be filled for the 8th month and the9th month.

If a woman delivers outside the village and returns to the village within 28 days, visit her andfill the Pregnancy Form. For Part II of the form, ask her if she had any of the mentionedconditions and complete the columns of 8th and 9th months.

4. Explain the unfamiliar terms (see the Content Box below):

Content Box

Definitions Swollen face and hands :. Face very puffy, larger than usual;

swollen hands; when a finger is pressed on the backside of thehand an indentation stays for a while

White discharge: from vagina (could be itchy, smelly, cheesy) Burning when passing urine: pain or burning sensation Bleeding: any bleeding from the vagina while pregnant Night blindness: difficulty seeing at dusk/night Fever: while pregnant Scabies and itching: red bumpy irritation, often between the fingers, or on the front

of the wrist, with intense itching especially at night Sores, boils, abscess with pus: note any of these on the skin

5. Discuss the different terms; ask if CHWs know about or have experience with them.6. Distribute HO-2 and ask the trainees to observe the photograph of the woman with swollen face

and hands.7. Ask for questions and clarify as needed.

Demonstration: Filling in the Pregnancy Form - Part II (1 hour)


1. Using HO-3 Case Presentations, read each sentence and fill in the form.2. Ask trainees to follow on their practice forms.3. Ask for questions and clarify.


Session 9 Home visiting and use of the Pregnancy Form - Part IITrainer Notes


Practice: Filling in the Pregnancy Form-Part II through role plays (1 hour 15 minutes)


1. Divide the CHWs into two groups. Each group has one trainer.2. In each group, have the CHWs divide into pairs. Have each pair perform a role play in front of the

rest of the group. The task is that one CHW plays a pregnant woman at 8 months, and the other playsa CHW coming to do a home visit at 8 months and filling in the Pregnancy Form Part II.

3. All other trainees and the trainer observe the role play. The trainees complete the Pregnancy Form– Part II along with the CHW. After the role play the form is reviewed; the trainee playing theCHW reads each entry while other CHWs and trainer follow along and correct the mistakes if any.

4. Continue this until all trainees have a chance to record on the Pregnancy Form.5. Review the forms to see if trainees filled them in correctly.


Ask trainees to define each of the new terms or definitions. Ask a trainee to explain the different questions on the Pregnancy Form. Make corrections if any and add missed information. Compliment the CHWs for their good work.



Explain the timing of the CHW visits to the Questions and answers.pregnant woman during pregnancy.

Define terms in the Content Box. Trainees give correct definitions of terms.

Complete Part II of Pregnancy Review the completed PregnancyForm correctly. Form- Part II.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 9 Home visiting and use of the Pregnancy Form - Part IITrainer Notes


Pregnancy Form: Information of the Pregnant Woman (Mother)

Part II8) Information of the present pregnancy (questions a to f)

a) In the present pregnancy

8th month 9th monthSwelling on face and/ or hands Yes/No Yes/NoBurning sensation when urinating (for more than 24 hours) Yes/No Yes/NoWhite discharge Yes/No Yes/NoBleeding Yes/No Yes/NoNight blindness Yes/No Yes/NoFever Yes/No Yes/NoScabies Yes/No Yes/NoAbscess/boils/pus, on skin Yes/No Yes/NoDo you eat till you are full? Yes/No Yes/NoHow many times in a day do you eat? 1 2 3 4 1 2 3 4

b) Any other illness or problem?1) _______________________________________________________________________________

2) _______________________________________________________________________________

c) Did you have fever during the seven days prior to delivery? Yes / No

If you have taken treatment what was it? __________________________________________

Who gave treatment? ____________________________________________________________

d) In which month(s) of pregnancy did you receive iron folic tablets ?

1 2 3 4 5 6 7 8 9 Did not get

In which month(s) of pregnancy did you take iron folic tablets ?

1 2 3 4 5 6 7 8 9 Did not get

e) How many TT injections did you take during pregnancy? First Second Third Did not take

f) Did you have one or more antenatal check ups during pregnancy? Yes / No

If yes, in which months? 1 2 3 4 5 6 7 8 9

Where was the checkup(s) done? – PHC Nurse Private Hospital District Hospital


HO-1


For Supervisor

Form was checked by : Name Date

Corrections _________________________________________________________________________

____________________________________________________________________________________

Any different information ___________________________________________________________

____________________________________________________________________________________

Is the form complete? Yes / No Signature Supervisor



Swollen Face and Hands with indentations


HO-2


Case Presentation

Use the following cases to fill in the Pregnancy Form - Part III.

1) Shakuntalabai of village Murza is 7 months pregnant.2) She developed swelling of both hands.3) She has no complaint of white discharge.4) She has no burning when she urinates.5) She does not suffer from night blindness.6) She has not had fever during the pregnancy.7) She has not had bleeding during the pregnancy.

II.1) Meenakshi is 9 months pregnant.2) She has no swelling on her hands or face.3) She has no bleeding.4) She has no night blindness.5) She has no fever.6) She has no white discharge.

TRAINER GIVES TWO OTHER CASES, CHANGING THE MOTHER’S NAME, MONTH OFPREGNANCY AND SYMPTOMS.

TRAINEES PRACTISE BY FILLING PART II

Remember: If the case presentation does not mention that a woman has a problem (for example a feveror swollen hands), then assume she does not have the problem.




Session 10: How the CHW relates to the Traditional Birth Attendant(TBA)


PurposeTo ensure that CHWs understand the importance of cooperating with the TBA, to discuss situations

that may occur and to practice handling these situations.

Objectives

At the end of the session the CHW will be able to:1. Explain the role of the TBA in HBNC (covered in Module 1 Session 1 but reviewed in this session).2. Explain how she will talk with the TBA and develop a working relationship.

Materials

Training Aid 1: Model Role Play Script: TBA-CHW Relationship

Preparation

Make photocopies of Training Aid 1 for the use of trainers when they perform the scripted roleplay.

Training Methods

Small Group Discussion (15 minutes)

Instructions to Trainers :1. Divide the trainees into four groups.2. Have each group conduct a short discussion on:

role of the TBA importance of the TBA to HBNC how to develop a cooperative relationship with the TBA possible problem situations how to handle problem situations


Session 10 How the CHW relates to the Traditional Birth Attendant (TBA)Trainer Notes


Large Group Discussion (20 minutes)

Instructions to Trainers :1. Bring the four groups together.2. Have one person from each group summarise what was discussed. Use the same five questions to

guide the discussion: role of the TBA importance of the TBA to HBNC how to develop a cooperative relationship with the TBA possible problem situations how to handle problem situations

3. Focus on what a CHW would do if the TBA was not cooperating with her. For example, try talkingwith the TBA assuring her that she is only there to help with the baby, they are not in competition,etc. If problems continue, discuss the problem with the supervisor.

4. Summarise.

Model Role Play by the Trainers and Role Plays by Trainees (45 minutes)


1. Perform a role play using Training Aid 1: Model Role Play Script.2. Afterwards, discuss the issues raised: Did the CHW handle the problem correctly? What else could

be done? There are many feelings being expressed by the TBA.3. After the initial performance, read a few sentences of dialogue at a time, pause, and ask what the

TBA is feeling? How else can the CHW respond?4. Ask trainees to perform role plays to establish relationship with TBA. Provide them the following

role play situations: TBA feels that the CHW is better educated and will take away her job. TBA cannot believe in what the CHW says about her job description. TBA feels someone is necessary at the time of delivery who can help her. TBA wants clarification about the payment of CHWs.

Summary

Ask a trainee to explain the role of the TBA in HBNC. Ask a few trainees how they will talk with the TBA and develop a good working

relationship. Make corrections if any and add missed information. Congratulate the CHWs for their good work during the session.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 10 How the CHW relates to the Traditional Birth Attendant (TBA)Trainer Notes



Session 10 How the CHW relates to the Traditional Birth Attendant (TBA)Trainer Notes



Explain the role of the TBA in the HBNC Questions and answers.project.

Explain how she will talk with the TBA Role plays by the trainees.and develop a working relationship.


Model Role Play Script: TBA-CHW Relationship

Total time: 30 minutes (5 minutes acting, 25 minutes discussion)

Introduce the characters and scene to the CHWs: The TBA calls the CHW to the delivery, hours afterthe birth. CHW visits TBA at her house.

CHW: Hello! How are you?

TBA: Why, I had sent a message for you to reach Shanta’s house. She delivered the baby today.

CHW: I know. I rushed to Shanta’s house as soon as I got the message – hours after mid-day, but found

she had already delivered the baby very early this morning. Don’t you think that message was

given to me very late?

TBA: What was the use of troubling you at that early hour? After all I was called and was present right

from 2 am in dead of night and left only after the baby was born and Shanta was settled.

CHW: But don’t you remember …we had agreed that I should be called as soon as the labour starts. I

wonder why even Shanta’s family didn’t call me…

TBA: I only told them not to unnecessarily collect the whole crowd. I have been attending deliveries

since so many years and haven’t required any help from women like you. I hear you are to take

care of the baby. So now go ahead and do your job. Why should you interfere with my work?

CHW: I think you misunderstood what I told you and what you learned in the training you received

from (name the NGO or Trainer/Supervisor). I will not interfere in your work. Presently I am

learning my job of taking care of newborns and so it is important for me to observe the baby right

from birth.

TBA: So you want an entry under this pretext. Slowly you will start interfering under the garb of

helping me and also claim my share of money which I should get from the family.

CHW: Please! Please! Rest assured that I will not claim any money from the family. If you want you can

come with me the next time I visit a pregnant woman. I will, in your presence, tell them clearly

that no share of the ‘TBA’ money should come to me.

TBA: Okay, but maybe you will learn the job of delivery and village people will start calling you instead

of me.



CHW: No, rest assured! I vouch that neither will I interfere in your work nor replace you! The whole

point is that we are to work together! You are to manage the delivery and take care of the mother

and I am to care for the baby. Don’t you remember that in Gadchiroli district, when a CHW

worked with the TBA they were able to really improve how the baby and mother fared.

TBA: Yes, that’s true. Alright hmmm…

CHW: Don’t you remember about the 5 rupees you collect for registering a birth?

TBA: Yes…

CHW: Did you forget? You only get it when I attend the delivery!

TBA: Oh. Anyway it’ll be good having some help. Meerabai is going to deliver any day now…. I’ll call

you in time.

CHW: I’m happy that we can work together to help women and babies in the village.


Training Aid 1



Session 11: Field practice and use of the Pregnancy FormDay : 4Time Required : 3 hours 45 minutes field work; 1 hour 30 minutes review in session

PurposeTo provide hands-on experience to CHWs in carrying out registering and screening during pregnancy.


1. Demonstrate basic communication skills when talking to community women in their homes.2. Prepare the ‘List of all women in the village who may get pregnant’.3. Prepare the ‘List of pregnant women’.4. Demonstrate basic use of the Pregnancy Form when registering pregnant women and during visits

at 8 and/or 9 months.

MaterialsComplete set of following records for all trainees: ‘List of all women in the village who may get pregnant’ (Module 2 Session 3 HO-1) ‘List of pregnant women’ (Module 2 Session 7 HO-1) Handout 1 (HO-1): Pregnancy Form (Parts I and II) Communication Guide( Module 2 Session 1 HO-1) to observe communication in the field (also to be

used as part of CHW Progress and Evaluation Booklet (skill 1) when observing CHW during workin their communities)

Preparation Trainer/supervisor informs the community ahead of time of the visit and seeks cooperation. Trainer/supervisor chooses appropriate homes for visiting so that trainees get practice using all

forms (at least one home with a pregnant woman). Trainer/supervisor should arrange that no group visits a home already visited.

Training MethodsField Practice (3 hours 45 minutes)

Instructions to Trainers :1. Divide trainees into four groups (of 4-5 per group) to visit five homes.2. Clearly explain what the trainees are expected to do in the field (training objectives for this session):

Interview women using good communication skills.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 11 Field practice and use of the Pregnancy FormTrainer Notes


Start working on ‘List of all women in the village who may get pregnant’. Start working on ‘List of Pregnant Women’. Practice working with the Pregnancy Form – Registering pregnant women and screening in 8

and 9 months.3. Explain that this field work will be different than in their home communities because back home

they will mostly know all the women they visit.4. Be sure to be present in the village during the field work to support trainees if needed and solve

problems if they arise.5. Ask one trainee to take the lead interviewing in one household (all trainees will have a chance).

Other trainees fill in their records based on the woman’s answers.

Small Group Discussion: The field work experience (20 minutes)Instructions to Trainers :

1. Have each group meet separately to discuss their field experience pertaining to: How they felt talking to village women and explaining their role Feedback from trainees in group on how well the interviewer communicated Ability to fill in forms Difficulties faced

2. Choose a person to report to the larger group.Large Group Discussion: The filed work experience (1 hour)

Instructions to Trainers :1. Facilitate a discussion of the whole group.2. Have each group report on the summary of their experience.3. Lead a discussion, focusing on how to solve any problems.

Summary (10 minutes) Ask trainees to summarise their field experience. Add to the summary and connect the experience to the learning objectives. Based on experience in the field, highlight areas that may need more attention. Make corrections if any and add missed information. Congratulate CHWs for their good work.

The trainer evaluates his/her own session


Demonstrate basic communication skills Field practice. Observation (usingwhen talking to women in their homes. Communication Guide as a reference)

by fellow trainees during visit.Prepare the ‘List of all women who may Field practice/review of list.get pregnant’.Prepare the ‘List of Pregnant Women’. Field practice/review of list.

Demonstrate basic use of the Pregnant Field practice/review of listMother’s form when registering pregnantwomen and during visits at 8 and/or9 months.


Session 11 Field practice and use of the Pregnancy FormTrainer Notes


Pregnancy Form: Information of the pregnant woman (mother)Part 1

1) Date of filling in the form 2) Age of mother (full years) 3) Mother’s full name4) Place of usual residence of mother Taluka 5) Education (Mother) Education (Husband) 6) LMP Date Month Year / INDE7) Ask the pregnant mother the following information:History of previous pregnancies

Sr. No ofPregnancy 1 2 3 4 5 6 7 8 9 10Completedgestationperiod atthe timeof deliveryAbortion Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/ Yes/



Part 28) Information of the present pregnancy (questions a to f) a) In the present pregnancy

8th month 9th monthSwelling on face and /or hands Yes/No Yes/NoBurning sensation when urinating (for more than 24 hours) Yes/No Yes/NoWhite discharge Yes/No Yes/NoBleeding Yes/No Yes/NoNight blindness Yes/No Yes/NoFever Yes/No Yes/NoScabies Yes/No Yes/NoAbscess/boils/pus, on skin Yes/No Yes/NoDo you eat till you are full? Yes/No Yes/NoHow many times in a day do you eat? 1 2 3 4 1 2 3 4



b) Any other illness or problem?1)

2)

c) Did you have fever during the seven days prior to delivery? Yes /No

If you have taken treatment what was it? ___________________________________________

Who gave treatment? _____________________________________________________________

d) In which month(s) of pregnancy did you receive iron folic tablets ?1 2 3 4 5 6 7 8 9 Did not get

In which month(s) of pregnancy did you take iron folic tablets ?1 2 3 4 5 6 7 8 9 Did not get

e) How many TT injections did you take during pregnancy? First Second Third Did not take

f) Did you have one or more antenatal checkups during pregnancy? Yes / No

If yes, in which months? 1 2 3 4 5 6 7 8 9

Where was the checkup(s) done – PHC Nurse Private Hospital District Hospital

For Supervisor

Form was checked by : Name Date

Corrections

Any different information

Is the form complete? Yes / No Signature

Supervisor


HO-1



Session 12: Qualities of an ideal CHW


Purpose

To increase CHW understanding that positive attitudes and behaviors as well as knowledge of therole and skill are necessary to perform well. A CHW’s attitude toward serving people in the communityand her motivation to help and learn are among many qualities that need to be fostered.

Objectives


1. List the qualities a CHW needs to possess in order to excel at carrying out her role.2. Explain why these qualities are important to implementing HBNC.3. Demonstrate some of these qualities.

Materials

Blackboard or white paper Flip board for display of flipchart. Colored markers or chalk Training Aid 1: Story to Inspire CHWs

Preparation

The trainer should read through the Story to Inspire CHWs (Training Aid 1) and practice narratingthe story with emotion until he or she can do it without having to read it. If the head of an NGOwill be telling the story, ask him or her to prepare in the same manner.

Training Methods

Story Telling (15 minutes)

Instructions to Trainers :1. Tell the story found in the Training Aid; make sure not to read the story but to tell it with emotion.2. After the story, ask the CHWs what qualities were exhibited by the CHW in the story. Write these

on the blackboard or white paper.

Training Workshop 1Module 2 Working in the Community and Home - Visiting During PregnancySession 12 Qualities of an ideal CHWTrainer Notes


Large Group Discussion/Brain Storming (15 minutes)

Instructions to Trainers :1. Lead a discussion asking: “Think about being a mother in your community. What qualities would

you want the CHW to have who is caring for you and your baby?”2. List on the blackboard all the qualities mentioned that were not already mentioned in the story

telling exercise. Review each quality, remove some, add others, group some together, until youhave a list acceptable to everyone.

3. Ask the CHWs to copy the list in their notebooks. As the training progresses, they are supposed torevisit the list to see how they are growing as CHWs. (This list will be referred to in subsequentsessions).

4. Write the qualities on one side of the blackboard and opposite each one, the opposite quality (e.g.,kind, cruel).

Role Play (30 minutes)

Instructions to Trainers :1. Ask for two volunteers. Have them perform two role plays; one showing a positive quality, and the

other a negative quality.2. Discuss the role play; make sure the performers also mention ‘how they felt’ receiving and giving

such attitudes/behaviors.3. If there is time, continue for 2-3 more role plays.4. Tell CHWs, “These attitudes manifest themselves in our daily behaviour as well. Learn to be aware

of and observe your own behaviour.”

Summary (5 minutes)

Have a trainee ask the group to name qualities needed for a CHW to perform her job well. Have another trainee explain why these qualities are important to the success of HBNC. Make corrections if any and add missed information. Appreciate the CHWs for their good work.



List and demonstrate the qualities a CHW ‘Qualities of an ideal CHW’ list.should possess to excel in her job. Observe role plays.

Explain why these qualities are important Role play/summary discussion.to implementing HBNC.


Session 12 Qualities of an ideal CHWTrainer Notes



Story to Inspire CHWs

Meenakshi was a Community Health Worker in her village. She came from a poor family so she couldn’tcontinue her education past the 9th form even though she was very smart. She had always been a shy girl,but polite and thoughtful.

When the local NGO began a Home-based Neonatal Care Project, they interviewed many girls in hervillage looking for a CHW. They picked Meenakshi. Meenakshi herself couldn’t believe it. At the beginningshe didn’t have a lot of self-confidence and wondered if she could do the job.

From the first, when Meenakshi started visiting women in their homes, something happened. Shebecame very interested in the women. She liked talking to them and hearing their stories and about theirconcerns. They liked her too. They liked how polite she was, and they realized her concern was heartfelt.What at first was a chore – visiting every house – became something she looked forward to every 2 months.

After some time, Meenakshi attended a delivery in the middle of the night where the baby haddifficulty breathing. As she was taught, Meenakshi cleared the secretions and the baby gave out a big cry.

In another house Meenakshi helped a woman who had a very small and premature baby. WithMeenakshi’s help and patience, the mother learned how to take care of and feed the little one.

As the months rolled by, Meenakshi felt stronger. The villagers came to respect her and her self-confidence grew. She knew she still had a lot to learn but she felt she was making a contribution to thehealth and happiness of families in her community.



Module 3: Treating Minor Ailments in the Community (Part I)

Session 1: Cleanliness and handwashing by the CHW


PurposeTo emphasise the importance of correct handwashing and provide an opportunity for CHWs to practice

under supervision according to set criteria (handwashing checklist).


1. Explain why it is important to wash hands with soap and water.2. List when handwashing should be done.3. Wash hands according to the handwashing checklist.4. Explain two cleanliness habits CHWs should follow.

Materials Water Soap Brush (optional) Bucket Mug White Basin Handout 1 (HO-1): Handwashing Checklist

Preparation Make adequate photocopies of Handout 1 depending on the number of trainees. Gather all the materials listed above and have them ready for the demonstration and practice. You

will need one set of materials (soap, bucket with water, mug, and basin) for each small group of thePractice activity (3-4 sets).

Training Methods

Demonstration (15 minutes)


1. Explain why correct handwashing is important (see Content Box).

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)

Session 1 Cleanliness and handwashing by the CHWTrainer Notes


2. Demonstrate that apparently clean hands carry dirt; have one trainee rinse her hands in the waterin white basin. Even with clean hands, some dirt and dust can be seen against the white basin.People can get sick when hands are dirty.

Content Box

Importance of handwashing: One of the most effective ways to limit the illnesses from infection isthrough correct and frequent handwashing.

When to wash hands: Hands should be washed thoroughly after using the toilet, before preparingfood, and before touching a newborn or young baby. This means that when you enter a home tovisit a baby, you must wash your hands before touching the baby.

Why dry with hands up and elbow down? This way the germs and water drip to the elbowleaving the hands and fingers cleaner. Air drying is best as even a clean looking cloth may havegerms on it.

3. Distribute the Handwashing Checklist (HO-1).4. Show how to rinse hands if you have an assistant and if you don’t:

With assistant: Assistant pours water over hands with arms in ‘drying position’ (hands upand elbows facing the ground).

Without assistant: dip hands in a shallow basin and immediately lift hands into dryingposition (hands up and elbows facing the ground).

Mention that in the wet season, the CHW can stand close to a chula (stove) to help dryhands.

5. Demonstrate correct handwashing; read each step out loud as you perform it. 6. Let hands air dry (this could take up to five minutes). 7. Use the checklist when observing and evaluating trainees when handwashing. Trainees should use

the checklist when practicing and observing others.

Content Box

Handwashing Checklist

1. Remove bangles and wristwatch before handwashing.2. Wet hands and arms up to the elbow with clean water.3. Apply soap and scrub forearms, hands and fingers, especially nails, thoroughly.4. Rinse with clean water.5. Air-dry with hands up and elbows facing the ground.6. Do not touch with your hands the ground, floor, dirty objects after washing your hands.

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 1 Cleanliness and handwashing by the CHWTrainer Notes


Practice/Assessment (35 minutes)

Instructions to Trainers :1. Divide the group into 3 or 4 smaller groups, each with water and a bucket, basin, mug, and soap.2. Have each trainee practice washing her hands as her team members read the points in the checklist.

One team member helps trainee rinse hands.3. Move around the room observing and helping if needed.

CHW Cleanliness Habit

When you are leaving your home for visiting the newborn make yourself clean and tidy. Do not visit newborns if you are ill (cough, cold, fever, diarrhoea, skin infection). Cover your mouth if you cough or sneeze.Cold germs are carried by droplets from our nose and mouth (when we sneeze or cough) and they travel in the air or are passed on our hands. Wash hands after using the toilet, before preparing food, and before

touching a newborn or young baby. Always wash hands more frequently if you have a cough or cold, especially after blowing

the nose. Do not touch with your hands the ground, floor, dirty objects after washing your hands.

Summary (10 minutes) Ask when the CHW should wash her hands. Ask a trainee to explain what cleanliness habits the CHW should follow. Ask a trainee to volunteer to demonstrate how to wash hands according to the checklist. Make corrections if any and add missed information. Congratulate the CHWs for their good work


Session 1 Cleanliness and handwashing by the CHWTrainer Notes


The trainer evaluates his/her own session (during practice session)


Explain why it is important to wash hands Discussion.with soap and water.

Explain when handwashing should be done. Questions and answers.Wash hands according to the handwashing Each trainee is observed washing her hands.checklist. Trainers score each trainee using the

handwashing checklist.

Explain two cleanliness habits CHWs Questions and answers.should follow.

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 1 Cleanliness and handwashing by the CHWTrainer Notes


Handwashing Checklist

Number of Practices

Check list 1 2 3 4 5 6 7 8 9 10 11

1) Remove bangles and wristwatch.2) Wet hands and forearms up to elbow with clean water.3) Apply soap and scrub forearms, hands and fingers, especially nails, thoroughly.4) Rinse with clean water.5) Air-dry with hands up and elbow facing

the ground.6) Do not touch with your hands the ground, floor, dirty objects after washing your

hands.

Note: Use the checklist while observing the skill being implemented.When a step is performed correctly, place a tick in the box.When a step is not performed correctly, place a cross or ‘×’ in the box.Make sure to review the steps where crosses appear so performance can be improved.


HO-1



Session 2: Basic care of wound and skin problems


Purpose

To introduce the CHW to different kinds of simple wounds or skin problems that she can treat.

Objectives


1. Identify five different types of wounds or skin problems.2. Decide whether CHW can treat the wound or whether referral is needed.3. Treat simple wounds and provide advice on home care.

Materials

Gentian violet paint (1%) Cotton balls Soap Water (bowl and pitcher) Blackboard or white paper/flipchart Markers Handout 1 (HO-1): Basic Care of Wound and Skin Problems

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees. Gather the materials listed above (G.V. paint, cotton balls, soap, and water) and have them ready

for the demonstrations.

Training Methods

Presentation (30 minutes)


1. Briefly discuss the different kinds of wounds CHW can treat (see Content Box).

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 2 Basic Care of Wound and Skin ProblemsTrainer Notes


Content Box

Abrasion: skin gets scraped off. Cut: slice into the skin. If bleeding, apply pressure with clean cloth until bleeding stops. If cut

is deep, refer the person to the PHC or hospital, instructing them to apply continuous pressure to stopbleeding.

Sore: this may be an irritation from an insect bite, or an abrasion or cut that got infected withgerms. A sore looks irritated, red and may have some pus.

Boil: an infected hair follicle; it may have a yellow top (pus inside) and be red (irritated)around it.

Burns: superficial burns (over an area less than the palm of a hand) without blistering. If burnis over a large area or is on face, eyes or has blistering refer to hospital

How to Treat:1. Wash your own hands carefully with soap and water.2. Wash the wound well with soap and drinking water.

Be careful to clean out all the dirt with cotton ball soaked in water.Any dirt left in the wound can cause an infection.

3. Air-dry the wound.4. Apply gentian violet (G.V.) paint to wound with clean cotton ball. (GV paint helps in

killing the germs on skin)5. Keep the wound uncovered for one minute. (GV paint colors the clothes and fingers.

Hence, minimise the contact. )

Advise Patient: Not to apply dust, dung or dirty materials on the wound. To clean the wound daily and apply GV paint three times a day until wound heals. If the wound does not improve but becomes red, hot, painful, has pus, or a bad smell, go to

the PHC or hospital.

“Cleanliness is of first importance in preventing infection and helping wounds to heal.”(quotation from Where There is No Doctor by David Werner)

Demonstration (20 minutes)


1. Demonstrate how to treat basic wounds.2. Ask if anyone has a sore or wound (if not, pretend).3. Treat the wound, going step by step as outlined in the Content Box.4. Ask for any questions and clarify.


Session 2 Basic Care of Wound and Skin ProblemsTrainer Notes


Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 2 Basic Care of Wound and Skin ProblemsTrainer Notes

Role Play Demonstration (20 minutes)


1. Have two trainees do a role play in front of the whole group showing how the CHW would treata wound and give home care advice.

2. Discuss the role play having trainees comment on the appropriateness of the treatment and advice.Was anything missing?


Ask a trainee to explain the different types of wounds that CHWs can treat. Ask another trainee to explain what kinds of wounds need referral. Ask another trainee to explain what advice a CHW gives on home care. Make corrections if any and add missed information. Congratulate CHWs for their good work.



Identify different types of wounds or skin Questions and answers.problems.

Decide whether she can treat wound or Questions and answers.whether referral is needed.

Treat simple wounds and provide advice Role play and summary discussion.on home care.


Basic Care of Wound and Skin Problems

Abrasion: skin gets scraped off. Cut: slice into the skin. If bleeding, apply pressure with clean cloth until bleeding stops. If cut is

deep, refer the person to the PHC or hospital, instructing them to apply continuous pressure to stop bleeding. Sore: this may be an irritation from an insect bite, or an abrasion or cut that got infected with

germs. A sore looks irritated, red and may have some pus. Boil: an infected hair follicle; it may have a yellow top (pus inside) and be red (irritated) around it. Burns: superficial burns (over an area less than the palm of a hand) without blistering. If burn is

over a large area or is on face, eyes or has blistering refer to hospital

How to Treat:

1. Wash your own hands carefully with soap and water.2. Wash the wound well with soap and drinking water.

Be careful to clean out all the dirt with cotton ball soaked in water.Any dirt left in the wound can cause an infection.

3. Air-dry the wound.4. Apply gentian violet (G.V.) paint to wound with clean cotton ball. (GV paint helps in killing

the germs on skin)5. Keep the wound uncovered for one minute. (GV paint colors the clothes and fingers. Hence,

minimise the contact. )

Advise Patient:

Not to apply dust, dung or dirty materials on the wound. To clean the wound daily and apply gentian violet paint three times a day until wound heals. If the wound does not improve but becomes red, hot, painful, has pus, or a bad smell, go to the

PHC or hospital.

“Cleanliness is of first importance in preventing infectionand helping wounds to heal.”

(quotation from Where There is No Doctor by David Werner)


HO-1



Session 3: Using aspirin and paracetamol


Purpose

To introduce basic information on when to use aspirin and paracetamol, who gets it, and appropriatedoses.

Objectives


1. Explain the conditions for which aspirin and/or paracetamol are used.2. Explain which drug should be given to pregnant women and children under five.

Materials

Handout 1 (HO-1): Treating with Aspirin and Paracetamol

Preparation

Make adequate photocopies of Handout 1 depending on the number of trainees.

Training Methods

Presentation (1 hour 10 minutes)


1. Give presentation based on the Content Box below. Tell trainees they do not have to write everythingdown as they will be getting a handout.

2. After the presentation distribute the handout.3. Ask for any questions.4. Tell the trainees that they should study the contents of the handout as they will be tested on the

contents at the next training. After passing the quiz, they will be given aspirin and paracetamol todistribute if needed by people in the community.

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 3 Using aspirin and paracetamolTrainer Notes


Content Box

Treating with Aspirin and ParacetamolAspirin: white tablet 300 mgOther names of the same medicine: Aspro, Anacin, DisprinParacetamol: white tablet 500 mgOther names of the same medicine: Panadol, Crocin, Calpol

To avoid confusion, paracetamol tablets are larger than aspirin tabletsUse for : fever headache pain in joints backache (upper and lower) menstrual cramps sprain painful swelling, inflammation pain from sores, boils, ulcers pain from injuries

Desirable effect of tablets: reduces pain reduces fever lasts for 4-6 hours

Note: Aspirin and paracetamol do not cure the ailment. Pain or fever is reduced temporarily. For example,if fever is due to pneumonia, fever will be reduced for about 4-6 hours but the pneumonia will remainuncured and will need to be treated. Aspirin or paracetamol will not reduce coughing and fever mayoccur again.Possible undesirable effects: heartburn/acidity (aspirin) vomiting with or without blood

Precautions: Do not give for abdominal (stomach) pain. Do not take on an empty stomach. Only take after eating something. Do not give aspirin to people with acidity problem; it may cause vomiting with blood. Do not give aspirin to children below 5 years. Use paracetamol for children below 12 years, for people with acidity problem and for pregnant

women.


Session 3 Using aspirin and paracetamolTrainer Notes


Aspirin ParacetamolUse for: Use for:everyone Children up to 12 yearsEXCEPT Pregnant womenChildren under 12 People with heartburn/acidityPregnant womenPeople with acidity

Age Dose Age DoseBirth upto 1 year 1/8 tablet

Over 12 years 2 tablets 1 year upto less than 5 years ¼ tablet5 years upto less than 12 years ½ tablet

Pregnant women and other adults 1 Tablet For infants, mix with honey and breastmilk. For young children not breastfeeding, mix with honey and a little clean water.

How many times: Aspirin 3 times a day (morning, noon, bed time) Paracetamol 3 times a day (morning, noon, bed time) Do not continue for more than 3 days.

Summary Ask trainees to explain when to use aspirin and paracetamol. Ask which medicine to give for pregnant women or children under five years old. Ask when aspirin should not be given. How often are these medications given? Make corrections if any and add missed information. Inform the CHWs that they will learn more about the use of medicine in the next training

hands. workshop and they will be evaluated before they start treating illnesses. Congratulate CHWs for their good work.

The trainer evaluates his/her own session


Explain the conditions aspirin and/or Questions and answers/summary.paracetamol are used for.

Explain which drug should be given to Questions and answers/summary.pregnant women and children under 12.

Training Workshop 1Module 3 Treating Minor Ailments in the Community (Part I)Session 3 Using aspirin and paracetamolTrainer Notes



Treating with Aspirin and ParacetamolAspirin: white tablet 300 mg

Other names of the same medicine: Aspro, Anacin, Disprin

Paracetamol: white tablet 500 mgOther names of the same medicine: Panadol, Crocin To avoid confusion, paracetamol tablets are bigger than aspirin tablets.

Use for:

fever headache pain in joints backache (upper and lower) menstrual cramps sprain painful swelling and inflammation pain from sores, boils, ulcers pain from injuries

Positive Effect of tablets: reduces pain reduces fever lasts for 4-6 hours

Note: Aspirin and paracetamol do not cure the ailment. Pain or fever is reduced temporarily. For example,if fever is due to pneumonia, fever will be reduced for about 4-6 hours but the pneumonia willremain uncured and will need to be treated. Aspirin or paracetamol will not reduce coughing andfever may occur again.

Possible Negative Effects: heartburn/acidity vomiting with or without blood

Precautions: Do not give for abdominal (stomach) pain. Do not take on an empty stomach. Only take after eating something. Do not give aspirin to people with acid problem; it may cause vomiting with blood. Do not give aspirin to children below 12 years, to pregnant women, or people with heartburn/

acidity.


HO-1


Treat children under 12, pregnant women and people with heartburn/acidity with paracetamol.

Aspirin ParacetamolUse For : Use For :Everyone over age 12 Children under 12Except pregnant women Pregnant womenand people with acidity People with heartburn/acidityAge Dose Age Dose

Birth upto 1 year 1/8 tablet

Over 12 2 tablets 1 year upto less than 5 years ¼ tabletyears 5 years upto less than 12 years ½ tablet

Pregnant women 1 Tablet Other adults

For infants, mix with honey and breastmilk. For young children not breastfeeding, mix with honey and a little clean water.

How many times:

as per need Aspirin 3 times a day (morning, noon, bed time) Paracetamol 3 times a day (morning, noon, bed time) Do not continue for more than 3 days.



Training Workshop 1 Summary

Planning for work in the communityDay : 5Time Required : 45 minutes

PurposeTo summarise what was learned in Training Workshop 1; to explain to CHWs what they will be

required to do in the community after this training, and how their work will be supported and evaluated.

ObjectiveAt the end of the session the CHW will be able to:

1. Explain what work she will be doing in the community after this training period.

Materials Communication Skills guide (Module 2 Session 1 HO-1) ‘List of all women in the village who may get pregnant’ record sheet (Module 2

Session 3 HO-1) ‘List of Pregnant Women’ record sheet (Module 2 Session 7 HO-1) Pregnancy Form (Module 2 Session 11 HO-1)

Preparation Instruct the trainees in advance to bring their copies of the Communication Guide and other materials

listed above to this session.

Training MethodsInstructions to Trainers :

1. Have the CHWs review the activities the CHW will be doing in the community during the nextmonth. (making list of women who may get pregnant, and women who are pregnant, fill thepregnancy form in 4th month of pregnancy and health screening in 8th and 9th months.) The CHWsshould not start using GV paint, aspirin, paracetamol at this stage.

2. Ask the CHWs to review what they have learned during this training.3. Add anything that may have been missed.4. Explain that the supervisors will be visiting the CHW, observing her work, and helping her when

needed. A schedule for the supervisor’s visits should be arranged with all CHWs.Evaluation


Explain what work she will be doing in the Questions and answers.community after this training period.

Training Workshop 1 SummaryPlanning for work in the community

Trainer Notes


Post-Training Evaluation of CHWs at the Work Site

After the Training Workshop 1: Modules 1, 2, and 3

Name of CHW:__________________________________Date:__________________________

FOR USE BY SUPERVISOR

Objectives Checklist / × Write mistakes

1) Demonstrate Greeting.basic Explains why she is visiting today.communication Acts with confidence.skills when Speaks in a gentle tone of voice.talking to Uses simple words in local language.women in Is respectful.community Asks the woman if she has any questions

Answers clearly.Thanks her at the end of the visit.Says when she will return.

2) Prepare the All the names in the list are of village women.‘List of women In each home visited, names of all eligiblewho may get women entered in the list.pregnant’ Age of women written correctly.

The names of women who are pregnant andbelong to other villages are not taken on thelist of women who may get pregnant.

3) Prepare the Names of women are taken on the pregnant ‘List of women list after the women complete four pregnant months of pregnancy.women.’ Names of pregnant women who are the

visitors in the village are not in the list.4) Demonstrate Has the form been filled for pregnant womenbasic use of the after completion of four months of gestation?skills required Check the table of obstetrical history.for completing the ‘Yes’ does not appear in any two rows in thePregnancy Form same column.when registering Has the column for the 8th month beenpregnant women filled correctly and completely?and during Has the column for the 9th month beenvisits at 8 and filled correctly and completely?/or 9 months

Post-Training Evaluation of CHWs at the Work SiteAfter the Training Workshop 1: Modules 1, 2, and 3


Documents

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