Home Based Postnatal Care

TRAINING OF CHILD HEALTH MANAGERS

120

109.3
100
94.9
35
78.5
80
67.6 74.3
21.5
60 48.6
57.0
43.4
39.0
40 9.6

20

0
NFHS 1 NFHS 2 NFHS 3

Neo- natal mortality Infant mortality

Under five mortailty

 Why Focus on Neonatal Care

 Considerable improvement in child health made in India

 Reductions are mainly in both postneonatal and 1–4-year-
old child
 A disproportionate burden of infant and under-5 childhood
mortality relates to deaths within the neonatal (0-28 days)
period which has remained constant
 India has the single highest share of neonatal deaths in the
world;
 Out of the 4 million neonatal deaths globally, one million
neonates die in India, i.e. one child dies every 2 seconds.
 Why Focus on Maternal Health during
Postnatal Period
India has the dubious distinction of having the
highest estimated number of maternal deaths in any
country - 117, 000 out of 536,000 (WHO 2005)
Accounts for 22% of all maternal deaths globally;
over 320 women die every day due to pregnancy and
childbirth complications
All pregnant women are at risk and can develop
complications at any time during pregnancy, delivery
or after delivery
 Need for HBPNC

Providing effective care for mothers and newborns

during the early post-natal period has the potential to
generate the greatest gains in survival and health of any
period in the continuum of care
Up to two-thirds of neonatal deaths can be prevented if
mothers and newborns receive universal access to
antenatal care, skilled birth attendance and early
postnatal care.
Neonatal care delivered at two sites
 At home - HBPNC
 At health Facility – SNCU, SNSU
 Who; Where; When;

Who for? Integration of post-natal care for mothers and

newborns provides more effective and efficient care than
separate approaches to post-partum and newborn care.
Where? Routine post-natal visits should be provided at
home, both to promote healthy behaviors and to link
with curative care – instead of just hoping that the
mother or baby will be brought to a health facility if
problems arise.
When? Early contact with mothers and babies is critical,
ideally within 24 hours of birth for the first visit.
 Delivery of Services

Home Visits by a Community Health Worker after

birth forms an important strategy
HBPNC is a range of interventions that are packaged
for delivery
 At different times during pregnancy, childbirth, and after birth,
 Through various health-care providers in community settings
(ASHA, AWW and ANM – the “triple A” of community health
providers).
 Core Principle of HBPNC

The core principle of the HBPNC model is the

“Continuum of Care”- from Pregnancy, birth and
during the newborn period and a continuum of care
Home and community, to the health centre and
hospital and back again.
Promoting improvement in household behaviors
through Home Visits by ASHA at critical times and
consists of three parts
 Parts of HBPNC

A special training program (2+5 days) in Home

Based Newborn Care
An incentive to the ASHA for completing PNC
checkup routine
A referral fund to ensure that sick newborns and
mothers can be referred to a facility with proper care
available
 Components of HBPNC

1. Ante Natal – Birth Preparedness

1. One Home Visit
2. Post natal – Care of Newborn and Mother
1. Six Home visits
 Activities during Home Visits by ASHA

Assessment of the health status of the newborn and

the mother; looking for danger signs and making
referrals, as appropriate
Counseling, especially on essential newborn care and
breastfeeding, and also on immunization and family
planning
Documentation (supporting birth registration and
on findings and process of care)
 Activities during Pre-natal Visit

Counsel the family about JSY scheme and benefits

of institutional delivery
Prepare one family member for supporting the
mother during and after delivery
Ensure the mother has JSY beneficiary card and
ANC card
Items required for facility/home delivery are kept
ready
 Activities during Pre-natal Visit … 2

Counsel for early initiation and exclusive breast

feeding
Examine the breasts and treat flat/inverted nipples
Educate the family when to inform ASHA
Other preparations including transport
Plan for emergency situations - Educate family on
danger signs and suggest the need for immediate
referral – When, Where and How
 Activities of ASHA if Present During Home
Delivery
Ensure
Five cleans during delivery
Baby is dried immediately after birth and wrapped
appropriately
Birth weight is recorded
Baby is put on to mother’s breast within one hour of
birth
Examine baby and mother for danger signs
Advice for delayed bathing
Schedule of Postnatal visits
 Schedule of Postnatal visits

Visit Timing
Visit 1 Day 1 of birth
Visit 2 Day 2-3 after birth
Visit 3 Day 5 – 7 after birth
Visit 4 Day 14 -17 after birth
Visit 5 Day 23 – 28 after birth
Visit 6 Day 42 – 45 after birth

Managers need to understand basics of newborn care in order to conduct effective

validation visits to the families. Keep a check list ready related to validation visits.
 Visit 1 - Day 1 of Birth

ASHA to examine the newborn for:

• Alertness :
• Activity
• Breathing
• Color
• Temperature
• Malformations
2. Record birth weight
3. Enquire initiation of breastfeeding and assess for positioning and
attachment, demonstrate to the mother
4. Counsel mothers/caregivers on Breastfeeding, Keeping baby warm,
cord care, Hygiene, Delayed bathing, Danger signs for baby and mother
5. Examine mother for heavy vaginal bleeding, fever, pain, problem
with urination, breast problem
 Visit 2 - Day 2 to 3 after birth
Same as the first visit. Additionally Looks for:
1. Jaundice
2. Feeding pattern, is the baby being exclusively breast fed
3. Passage of urine and stool
4. Cord condition
5. Skin Pustules (puss pockets on the skin)
6. Check if birth registration is done
7. Check if the baby received BCG and zero dose of OPV
8. Counsel mothers/caregivers* on Breastfeeding, Keeping
baby warm, cord care, Hygiene, Delayed bathing, Danger signs
for the baby and mother
9. Ensure birth registration
Manager can cross verify from mother if she was informed
about care for low birth weight baby/cord care and when to
bathe.
 Visit 3 : Day 5 – 7 after birth

All activities as the second visit:

1.Counsel the mother and family on newborn care
2.Observe the feeding practices; record observation and
counsel mother for correct practices
3. Check the condition of the cord
4. Weigh the baby and record it in the PNC card
5. Counsel the mother for adequate rest and nutrition
6. Identify danger signs in the mother and the newborn
and make referral 
Supervisors and BCHM need to validate if ASHA uses the
weighing scale correctly and records weight it in the PNC
card.
 Visits 4 - Day 12-14 after birth

All activities to continue as in visit 3:

Routine examination & referral if the newborn is
identified with danger signals.
Check if the couple opted for FP options
Check if the mother is bleeding excessively or has any
other danger sign; if needed, make referral
Check if the mother practices hygiene related messages
Weigh the baby and record weight gain
 Facilitate zero dose immunization if not given at birth
BCHM must check the process of referral from mother
 Visit 5: 23-28th day-role of ASHA,

Check if the couple opted for FP options

Check for danger sign – mother n baby
Check if the mother practices hygiene related
messages
Record the weight of the baby and look for weight
gain
Counsel for RI
 
 Visit 6 : Day 42 – 45 after birth

• Routine examination of the baby and the mother and advise

accordingly

• Weigh the baby and look for weight gain

• Counsel the mother on immunization of the baby

• Counsel the mother on spacing

 Tools for ASHA

 Recording home visits and events

 PNC card for recording the visits and findings
 Referral card
 Register for recording

 Supporting tools
 Weighing scale and sling
 Thermometer
 Flip chart for counseling
 ASHA Booklets
 Reference sheet
 Additional components in ASHA kit
 Role of Supervisors
(e.g.ANM, LHV)

1. Identify facilities and/or medical personnel for

referrals along with the MO/IC
2. Support ASHA/AWW in identifying referral system
in the village
3. Random validation of home visits- 5% sample check
(orissa2%) and checking the PNC for accuracy and
completeness
4. Ensure that ASHA is maintain the counterfoil of the
PNC
5. Ensure availability of referral funds with ASHA
 Role of Supervisors
(e.g.ANM, LHV) Contd……

7. Ensure that the birth is registered

8. Inform the Block manager in case there is shortage
of PNC card or Referral slip or other equipment
(weighing scale, thermometer etc)
9. Check that ASHA has the counterfoil of the Referral
slip in case a child has been referred
10. Check if ASHA is using the Flip book and other
literature provided to her
11. Ensure incremental capacity building of ASHA
during the field visits and also in the monthly review
meetings
 Role of Managers

1. Understand the significance of ASHA making the five

visits
2. Identify facilities and/or medical personnel for referral
3. Support ASHA/AWW in identifying referral transport
from the community
4. Ensure that the hospital have system for respecting the
referrals made by ASHA
5. Coordinate with DHS for replenishing ASHA kit
6. Organize ASHA capacity building to ensure correct and
complete recording in the PNC card
7. Undertake random validation home visits and check the
PNC card for accuracy and completeness
 Role of Managers Contd…

7. Ensure availability of referral funds with ASHA

8. Establish a system to ensure that the PNC cards are being
delivered at the Block on time
9. Establish a process to ensure that the PNC cards are being
entered in the database correctly at the block
10. Cross validate the progress reports for compliance of
guidelines
11. Ensure that ASHAs have the PNC cards, registers, Flip books
Weighing scale, thermometer and use them appropriately.
12. Establish a system with MoIC and Block accountant for
ensuring timely incentive payment to ASHA
13. Incremental capacity building of ASHAs during field visits
Display PNC Card and Referral
Card
 Importance of PNC Card

Purpose of filing the PNC card is to gather data on the

• Number of mothers received counseling on newborn care,
• Number of neonates identified with sickness and danger
signs and referred
• Number of mothers or neonates died in that community.
• Gender differentials in the data

Role of the Supervisor

• Should verify and check the quality of the PNC cards filled
by ASHA .
• Needs to ensure that the filled PNC cards reach the MoIC
on time and for further processing for incentive payment
 Importance of PNC Card –
Role of the manager
• To collect the data electronically for better analysis
• Further refinement of the processes based on the
findings
• Review the progress based on the data and develop
strategies
• Establish a system to get feedback from ANM/LHV/
external agency , regarding quality of the information
filled in the PNC card and develop a system of
dissemination.
• Ensure that all supervisors, MoIC, Block accountant and
ASHAs are aware of the various steps to complete the
process.
 Role of Manager in Incentive
and referral fund management

Managers must:
• Ensure that the block PHC has received the necessary
funds for making timely incentive disbursement to ASHA,
supervisor and Accountant .
•Ensure that the accountants have clarity on the ASHA
incentive payment instructions and schedule for payment is
available.
• Ensure that the ASHAs receive the referral fund with
them from the Block PHC after completing the necessary
training
 Role of Manager in Capacity Building

•All the TOT are planned and organized in the

respective blocks as per plan
• A block training calendar is developed and the
schedules are communicated well in advance to all the
trainers, Block MoICs, ASHAs and accountants
• Ensure that the required budget is made and
approvals are obtained on time for ensuring the fund
release.
• Develop a checklist related to all the aspects that
require coordination with the CMHO/MoIC
 Capacity Building Checklist -
Coordination
o Fund release
o Availability of resource persons
o Travel arrangement for the participants and resource
persons
o Training materials, training aides
o Venue
o Transport
o Boarding and lodging arrangement for the trainees and
resource persons
o Honorarium to the resource persons
o Practical facilities such as toilets, drinking water, power
supply at the venue