Making House Calls for India's Mothers and Babies

Women and their newborns in rural Uttar Pradesh are getting better care, thanks to frontline health workers like Vidya.

For every 1,000 living babies born in Uttar Pradesh, 61 die before they leave infancy. The state has some of the highest rates of infant and maternal mortality in India. And in 2010, India accounted for 19% (or 56,000) of the world’s maternal deaths.

India’s government wants to change these numbers, which is why it launched the National Rural Health Mission in 2005. The next year, IntraHealth International began providing technical assistance to the mission, and we worked together to improve health and nutrition for 18.8 million mothers, newborns, and children in 24 districts across India.

On the front lines of India’s rural health workforce are some 850,000 ASHAs, or accredited social health activists, who make up a relatively new cadre of health workers for India. These are government-trained, female, lay health workers who travel throughout their rural communities, encouraging and teaching people to live healthfully and helping them to navigate the public health system when they need it.

The ASHA program has been popular and fast growing ever since it was rolled out as part of the National Rural Health Mission. While ASHAs aren’t paid salaries, they do get performance-based incentives from the India government for completing certain tasks—promoting immunization, for example, or escorting clients to health facilities.

Vidya is the ASHA for Alipura, her village in rural Uttar Pradesh. After she went through the initial training, she began making regular house calls to Alipura families and teaching them about nutrition, hygiene, and basic sanitation.

For new and expectant mothers, Vidya’s services are crucial. She counsels women on how to care for themselves and their babies, covering everything from childbirth preparation and breastfeeding to immunization and anemia.  

Vidya is the first point of contact for the people of Alipura and their primary link to the public health system.

The power of rapport

The IntraHealth-led Vistaar Project worked with the Indian government to strengthen the ASHA program, making sure that ASHAs have strong supervisors and mentors as well as opportunities to update their training—in short, helping to create the systems ASHAs need to do their very best work.

When the Vistaar Project began, the team found that the number of ASHA home visits was far too low. Less than 1% of new mothers surveyed, for example, had been visited by an ASHA within seven days of their deliveries. And the visits the ASHAs were making were not nearly as effective as they should have been. Mothers who had been counseled by ASHAs either couldn’t remember their advice or, for one reason or another, weren’t following it.

A big part of the problem, the Vistaar team found, was communication. A lot of ASHAs were sharing the right information, but there was no back-and-forth, no conversations with the mothers. ASHAs weren’t necessarily finding out, for example, whether a mother understood the ASHA’s advice or if the mother was having problems carrying it out. In short, they weren’t developing rapport.

Many of the health workers didn’t have the confidence, authority, or interpersonal savvy to convince young mothers (or their mothers-in-law, who are often the decision-makers in the household) of the best ways to care for newborns—especially when those ways go against customs that are sometimes centuries old.

A lot of traditional newborn care practices in rural India—such as giving babies river water to drink or rubbing mud, ointment, or herbs on the umbilical cords—can cause infection and diarrheal disease. It can take authority and perseverance for a young ASHA to convince families to make these kinds of changes.

“Earlier we just spoke to the mother-in-law and expected her to pass on the message to her daughter-in-law,” one ASHA told the Vistaar team. “Now we say, ‘No, I want to talk to your daughter-in-law.’ We are not scared to do that.”

Vistaar Project results

IntraHealth worked with the government of Uttar Pradesh to build the communications and counseling skills of the state’s ASHAs and provide structured, constructive gatherings where the workers can meet and learn from one another.

The Vistaar team helped restructure the existing monthly ASHA meetings—which had started out as irregular, chaotic gatherings of up to 150 women at a time—into consistent, smaller meetings of 40 to 50. The team also developed two-hour, interactive sessions on topics such as interpersonal communication, planning home visits, and critical messages about maternal health and newborn care, and offered them to ASHAs who want to hone their skills at the new, smaller meetings.

Through the Vistaar Project, IntraHealth has now helped the Indian government to train over 8,000 ASHAs in the state of Uttar Pradesh and strengthened their support systems in five districts.

By the time the project ended in October 2012, the Vistaar team found that ASHAs had begun to make more home visits. And more importantly, more mothers were retaining the ASHAs’ messages and putting them into practice.

You can read more in the end-of-project brief on this topic, but here are some highlights. Vistaar surveys revealed that by the end of the project:

  • Attendance at the ASHA monthly meetings rose from 48% to 74%.
  • Almost all monthly meetings included the new skills-building sessions.
  • 38% of mothers in rural areas reported being visited by an ASHA within a week of their deliveries, up from less than 1%.
  • The percentage of mothers who were breastfeeding within one hour of their deliveries rose from 15% to 28%.
  • The percentage of newborns being weighed at birth rose from 26% to 53%.
  • The percentage of newborns who were receiving colostrum—the antibody-rich milk mothers first produce—rose from 58% to 80%.
  • The percentage of mothers who were delaying bathing their newborns by at least three days rose from 37% to 59%.

An unexpected benefit

Now Vidya meets regularly with other ASHAs and can reach out to her supervisors whenever she has a problem. Not only does the training and guidance boost the quality of her work, it also makes the job more satisfying.

“Earlier I was locked up inside the house like any other daughter-in-law of the village,” Vidya says. “But since I undertook this role of being an ASHA, it has increased everyone’s respect for me. The community trusts me when I go door to door. I love my work.”

Vidya’s experience highlights an unplanned benefit of the ASHA system. Not only does the program improve the health of mothers and newborns in Uttar Pradesh, it also elevates the confidence and status of many young women within their communities.

The Vistaar Project, funded by the United States Agency for International Development, was a six-year initiative with India’s national government and the state governments of Jharkhand and Uttar Pradesh to improve health and nutrition in mothers, newborns, and children.