1

Operational Guidelines

for

Yashoda/Mamta

2

1. Rationale: The sudden influx of beneficiaries in public health institutions due to JSY has added to the challenge to provide quality maternal and neonate health care. However, it provides a window of opportunities to improve the RCH services at the facilities. Surveys on JSY show that many of the women stay in the institution for less than 24 hours after delivery, regardless of a normal delivery or a difficult delivery. UNFPA’s and GTZ’s evaluation of JSY in 2007 raised several issues about its benefits and processes for the women. These include: the duration of stay at the facility, the quality of services, the facilities available at the hospital, the safety of mother & child, and the availability of counselling on follow up visit, breastfeeding, immunization, family planning, newborn care and diarrhoea management, etc. The first 24-48 hours after delivery offer a golden opportunity for integrating neonatal care with postpartum care. Many of the conditions responsible for the mother and/or neonate’s death are recognizable in the first 48-72 hours after delivery. This includes: hemorrhage, sepsis, eclampsia (responsible for more than half of the maternal deaths), birth asphyxia, sepsis, hypothermia, and low birth weight/ pre-maturity (responsible for more than 2/3rd of neonatal deaths). Therefore the government of India norms require that mothers stay in the hospital with the newborn for 24-48 hours after delivery. Can a person from the existing facility be found: to make the pregnant women feel welcome at the facility, to make her feel comfortable after delivery, to initiate exclusive and immediate breast feeding, to counsel the mother on basic newborn care, and to motivate the mother to stay at the facility for a longer duration? The hospitals, with increasing volumes of deliveries per day, have not been able to use this opportunity fully due to a shortage of nurses and a poorly managed logistics system. ‘Yashoda’, a dedicated non-clinical support worker, apart from helping motivate mothers to stay for a longer duration, would also assist the nurses with initial care for the mother and the newborn soon after the delivery. Why Yashoda, and why not ASHA? It has been observed that in almost 30-40 % of cases, ASHAs do not accompany the pregnant women to the hospital. Even those who accompany do have other responsibilities under NRHM and cannot be away from the community for over 24 hours. If we assume that ASHAs accompany pregnant women to a District hospital where 20-30 deliveries take place a day, in the course of two days, there will be 40-60 ASHAs at the hospital. There is no arrangement for their stay, food, or security. These additional people in an already stretched infrastructure can create chaos. The NIPI focus states have engaged ‘Yashoda’ /’Mamta’ at the facility level for facilitating the initial care that the newborn and the mother require during their stay at the facility, there by addressing the above gaps to some extent.

• Yashoda is not a regular employee of the health system at present. This innovation aims at introduction of a volunteer support worker paid a performance linked incentive, who acts as a catalyst and supports the nursing staff.

• She is not a substitute for the nursing staff or paramedical staff available at the facility. However, with appropriate support and capcity building, it is expected that competent Yashodas could be used in future as ‘Newborn Nursing-Aide’ to work in the Sick Newborn Care Units coming up in the District Hospitals and Stabilization Units in the Block hospitals.

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2. Role of Yashoda Yashodas have a range of responsibilities that of ensuring cleanliness and functionality of the ward, be a friend to the mother, to counsel the mother on nutrition for self and newborn, immunization and family planning choice etc. As a support worker for improving quality care, Yashodas also have the responsibility to facilitate safety, security, dignity and privacy of the mother and special and dedicated attention to the newborn. Since each mother and a healthy newborn leaving the hospital will be an ambassador for spreading the message of improved care at the institution, Yashoda’s role in building confidence of the mother becomes crucial .Yashodas’ will be given appropriate logistics and administrative support, mentoring and supportive supervision by the Child Health Supervisor(CHS) and Deputy Child Health Supervisor(DCHS) along with the nursing staff located at the hospital to fulfil the above tasks. 2.1. Providing a congenial environment: Yashoda makes the mother feel welcome and makes her stay comfortable by being friendly and cordial. She will function as an interface between the hospital staff, the mother and her family and will remove some of their apprehensions about the hospital, medication and paperwork. She will link with the ASHA accompanying the pregnant woman and gather basic information on completion of ANC check up, any problem etc, and inform the nursing staff for necessary action. She will assist the nurses in bed making and avoid crowding in the ward. 2.2. Newborn and mother care: Make the logistics arrangement to ensure cleanliness of the area, prepare the bed for the mother and baby, manage the food and other ancillary requirements of the mother and baby, and keep the paper work and the basic required drugs ready 2.3. Assist the nurse in post delivery care: receiving the newborn, cord care, assessing the vital signs, putting identification tags, taking the weight of the newborn, cleaning the newborn, draping the newborn in adequate sheet and blankets as per the weather Assist the mother to initiate immediate and exclusive breastfeeding Ensure all Zero-dose immunization from the institution.

2.4. Counsel the mothers and provide facts, sources, contact persons on: -Breastfeeding and complementary feeding; nutrition requirements for mother -Details about further immunization requirements, schedule, availability, etc -Preparations to be made in case of illness of the baby and mother -Prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infection (RTIs/ STIs) -Family planning advice as required including spacing, contraception -Accessing institutional care in future, if the need would arise for the baby/child, whom to contact, etc. 2.5. Motivate the mother to: stay at the facility for 24- 48 hours as per the guidance of the doctors.

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2.6. Initiate birth registration / procuring birth certificate: Yashoda will facilitate the filling of the forms for registration of birth and still birth. (The filled forms will be cross checked by the Child Health Supervisor and handed over to the nursing staff, which in turn get submitted to the municipality/ block from the hospital and to the Panchayat by the parents/ family members for registration, as per requirement).

2.7. Provide information on the follow-up after discharge from the health facility on the need for regular weight check ups, weight gain in the ensuing months, immunization, feeding of the baby (exclusive breast feeding till 6 months and introduction of complimentary feeding thereafter); contact points such as ANM, AWW, and other support systems in the community. 2.8. Informing family members present at the health facilities about: - Basic care for mother and newborn after leaving the facility including rest, nutrition, basic sanitation & hygienic practices - Existing health services, immunization days, and other maternal child health care services, especially for post natal care (provide by ANM and ASHA, supplementary nutrition services available at the Anganwadi centres) 2.9. Support to the nursing staff: Informing them about any abnormalities noticed in the condition of the mother or the newborn on a daily basis and around the clock. It is expected that the hands-on and continuous training of Yashoda will equip them with skills to identify the at-risk babies and mothers requiring extra stay at the hospital; maintain a monitoring chart for the baby and mother about vital parameters (temperature, respiratory rate of both newborn and mother and pulse rate of the mother) and problems encountered.

The pie chart given below is an approximate suggested time devoted by Yashoda for the various activities in a day during her shift.

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2.10 Record Maintenance This innovation requires appropriate follow up of the services rendered to improve quality. Monitoring effectiveness of Yashoda intervention contributing to increasing the duration of the stay of mothers, initiation of immediate and exclusive breast feeding and immunization, in addition to mothers receiving appropriate information on care for self and newborn after leaving the facility. Towards this, it is suggested that Yashodas maintain two sets of records, which are expected to facilitate the nursing staff as well as the Child Health Supervisors to make appropriate measures to improve the quality of service. 1). A daily record register keeping details of the each delivery in each shift ( See Annexure 1 for record format). This record will be filled and signed by all the Yashodas working in the three shifts to have continuity in the record. The Child Health Supervisors must ensure that the same record is filled by the Yashoda in their respective shifts in a day to have complete data on each mother and newborn. 2). Maintenance of pre and post feed back form. This will be filled on the basis of the feedback received from mother / accompanying family members, before and after the counseling sessions. The feedback form will specifically collect information from i) mothers having first delivery and (ii) mothers having subsequent deliveries. The Child Health Supervisors will collate the information on fortnightly basis and a) share it with the District Child Health Manager and nursing staff and b) use the information for mentoring Yashoda and seeking suggestion for improvement from the head nurse /matron to improve quality (Sample pre and post test feedback form is attached as annexure 1.A.)

Yashoda Time Piechart

20%

10%

20%20%

10%

10%

10%Essential Newborn Care

Maternal Care

Support to Breastfeeding General Support*

Counseling for care after discharge

Family Planning guidance

Ensure Cleanliness

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3. Yashoda Implementation process: 3.1. Preparatory activities: a) NIPI State program officers and State NRHM officers Orient the district officials (CDMO, ADMO/ Medical superintendent, DPM, DIO, doctors, matron, nurses) on the rationale, administrative and financial arrangements, mode of engagement, and training and monitoring of Yashoda. There are a number of steps to make the recruitment transparent and ensure the suitable candidates are selected for this position. b) State NRHM Mission will issue appropriate guidelines for recruitment, engagement, training, incentive disbursement, supervision, monitoring and reporting of Yashoda intervention. This process will be facilitated by the NIPI State program officers. c) Ensure transfer of funds to the Districts for the implementation based on the projected need. d) NIPI State Program Unit will actively seek support of the District Collector to fast track the selection and placement of Yashodas 3.2. Yashoda recruitment: a) Placing Local News Paper Advertisement: This will be placed by District Immunization officer (DOI) or Chief Medical Officer (CMO) /Civil Surgeon//RCH Nodal officer with permission from District health society (DHS). b) Suggested criterion for Selection:

- A local woman living near the hospital area - Preferably a mother of children who are not being breast fed - She agrees to work as a volunteer without intimidation of caste/ creed. - She will receive performance-based incentives - Her engagement as volunteer worker does not entitle her to claim the regular position

in the system - Free from communicable diseases, subject to clearance by the Medical Officer

- Willing to work on rotational basis including night duties Decisions on the criteria are to be finalised at the district level by the DHS and / or Rogi Kalyan Samiti (RKS) of the hospital.

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c) Short listed candidates will be invited for interview.

Suggested evaluation parameters of the candidates during interview: Parameters* Marks* 1 2 3 4 Additional 2 Education 8th Grade 10th Grade 12th Grade Graduate Nurse/ ANM

degree/ diploma

Age 50 + 45-50 25-35 35-45 NA Work experience

Never worked Worked in non –health sector

Worked as private nurse/ assistant

Worked in hospital setting

NA

Communication Skills

Poor Average Good Excellent NA

Family/ Dependents (Youngest Dependent child)

Breast feeding child

Less than 2 years

2-5 years More than 5 years

NA

Distance of residence from facility

> 5 Km from facility

3- 5 Km from facility

1-3 km from facility

<1 km from facility

NA

Willingness to work in rotation & at Night

Not willing for rotational duty

Only day shift

Prefer day shift

Willing to work any shift

NA

* The district authorities may modify the parameters/ weightage keeping in view the local need. 3.3 Mode of engagement of Yashoda: As Yashoda is a voluntary support worker, the engagement may follow the guidelines decide by the Hospital authorities /Rogi Kalyan Samiti in the respective states. Any mode of engagement should ensure that the roles and responsibilities, incentives, reporting and notice period etc are stated clearly without ambiguity and the Yashodas understand the voluntary nature of their work, compensation through a performance linked incentive system and does not entitle Yashoda for any claim for an adhoc or a permanent position in future. 3.4. Determining the required number of Yashoda in a district hospital This can be decided based on the number of deliveries occurring or number of maternity beds available in the facility. To provide around the clock services, Yashodas will work in 8-12 hourly shifts. We assume that one Yashoda will take care of about 4 -5 newborns delivered on each day in each shift. The newborn and mother are expected to stay for about 48 hours after delivery, so each Yashoda will take care of about 8 newborns over 2 days.

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Based on number of deliveries Based on number of beds Calculate the average number of deliveries per day a. Average number of deliveries per month (a)=

Sum of deliveries in last 3 months/ 3 b. Average number of deliveries per day (b) = a /

30 Calculate the number of Yashodas c. Required number of Yashodas in each shift (c) = Number of deliveries on each day (b)/ 4 d. Required number of Yashodas in three shifts = 3 x c Additional 20% Yashodas as buffer (Catering for attrition or drop out/sick leave/leave/duty off days) e. Total Yashodas required will be= 3c + 3c x 0.2.

a. Number of beds in maternity ward = (x) b. Lets assume the norm as 1 Yashoda for 5 beds (as per local need, finalised by the State) Calculate the number of Yashodas c. Required number of Yashodas in each shift (z) = Number of beds (x) / 5 d. Required number of Yashodas in each shift = 3 x (z) Additional 20% Yashodas as buffer (Catering for attrition or drop out/sick leave/leave/duty off days) e. Total Yashodas required will be= 3z + 20% of 3z.

Example: Assuming that in a district hospital total number of deliveries* in the last 3 months are 750, 760, 740 respectively. The average deliveries per month= 750 Average deliveries per day = 25 Required number of Yashodas per shift = 25/4= say 6 Required number of Yashodas in 3 shifts = 3 x 6= 18 Additional 20% of Yashodas required for 3 shifts as buffer = say 3 Total Yashodas required will be= 18 + 3 = 21.

Example: Assuming that a district hospital has 30 maternity beds*. Number of Yashodas in each shift = 30/5 say 6 Required number of Yashodas in 3 shifts = 3 x 6= 18 Additional 20% of Yashodas required for 3 shifts as buffer = say 4 Total Yashodas required will be= 18 + 4 = 22.

*This calculation takes into account all the mothers irrespective of whether they are on the bed or on the floor.

*This calculation takes the actual number of beds available in the facility and not those sleeping on the floor after delivery.

Keeping in view that all the mothers and newborns receive the services of Yashoda, it must be ensured that: • The duty roaster is prepared in such a way that work is distributed among all the Yashodas including the additional one. All Yashodas will be entitled for the incentives as per the duty roaster. Yashoda will also get one day off in each week plus 10 additional days in a calendar year, with prior permission. Her incentive therefore should be so computed so that she does not get penalised for the off days including the 10 leave days. Internal adjustments among Yashodas (including the buffer of 20%) may be made in order to ensure continuity in service. 3.5. Cost of Intervention : Total cost that will go into implementation of this quality care intervention will include incentives to Yashodas, training costs, supplies, Mother and Newborn kit, Maternity and

9

PNC ward IEC supports like wall decoration with mother and child motifs and other incidental costs. A proposed unit cost of Rs 140 per delivery has been suggested for all these activities. Out of this amount, Rs. 100/- is paid as incentive to the Yashodas for taking care of each newborn and mother. The rest Rs. 40 is spent on training, educational materials and other supplies. (See annexure 2 for detailed calculation of the various components of the incentive) 3.5.1. The monthly incentive for the Yashoda can be calculated as follows: Example:

• Assume that 750 deliveries occurred over a month in a district hospital with 21 Yashodas engaged, in 3 shift of 8 hours each. • Total number of shifts worked by all Yashodas in a month= 1890 ( 21 Yashoda x 3

shift duties x 30 days ). • Total incentive generated @rupees 100 per delivery =750 x Rs 100/- = Rs. 75000/-

• Incentive per Yashoda / per shift = Rs. 39.70 (75000 / 1890) • Monthly incentive earned by each Yashoda = Rs. 39.70 x 85 = Rs. 3375 /=

3.6. Incentive structure: The incentive for Yashoda may vary depending on the number of deliveries happening at the hospitals. The number of deliveries will fluctuate per month so the incentive for Yashoda will vary through the year. Although variation is expected, the incentive structure needs to be designed in way which ensures a minimum of Rupees 2750 per month and a maximum of Rupees 4000 per Yashoda. The ratio of Yashoda to newborn may vary from State to State. However, in order to ensure quality, each Yashoda should not be given more than 5 newborns to take care of on each day. 3.7. Options for calculation of incentive:

1. Payment on actual number: Based on the actual number of deliveries, incentives are calculated every month and paid to Yashoda. However, it should be ensured that Yashoda does not drop out during those months with lesser incentive.

2. Ensuring a stable income: A proportion of the incentives generated during the peak

delivery season can be kept aside as a buffer, to be used during the lean months. Any extra balance could be utilized at the end of the year as rewards/ special training for Yashodas to further build up their morale.

3. Fixed income: Based on the previous year deliveries, calculate the base minimum

incentive to be given in a month. Irrespective of the number of deliveries a certain amount will be given to Yashoda per month.

Other components under Yashoda initiative include: training, educational/IEC/BCC materials, other incidental costs apron/slipper/chair/table etc given to Yashoda. (For details see annexure 2)

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3.8 Payment Process a). Incentives will be paid on monthly basis.

b) Bank account of each SA will be opened in the same bank where account of Institution/RKS is operated.

c. The Child Health Supervisors will prepare monthly summary sheet of each

Yashoda based on the Yashoda daily reporting record. (see annexure 1 for format)

d. Child Health Supervisor will get the summary sheet verified and approve the payment voucher by the Head Nurse / matron by 3rd day of the following month. To fasten the payment process it is recommended that the head nurse/matron be

authorised to approve the voucher for payment of incentives based on the already approved norms.

e. The Child Health Supervisors will forward the duly approved summary sheet for

payment to District/Block accountant / RKS by 5th day of the following month.

f. The funds will be transferred in the bank accounts of Yashodas directly by 10th of the following month.

g. The RKS will submit the utilisation certificate to DHS on monthly basis. The

utilisation form will be the same as prescribed under NRHM

4. Training Capacity building of Yashoda is a continuous and incremental process that is critical to enhance her effectiveness. The capcity building is seen an empowering process, which will enable Yashoda to gain competencies progressively. Yashodas with certain level of competency could be further trained to become ‘newborn care aide ‘in the Sick Newborn Care Units and the Stabilization Units in the District hospitals and Block hospitals respectively. Induction training upon recruitment, continuous hands on training; refreshers training etc are to be carefully planned and designed to keep updating her knowledge and skills. Capacity building, in addition to the above training, must also include exchange visits, sharing of lessons learned, documentation of best practices etc. Mentoring and supportive supervision at the facility will also contribute to her capacity building. Giving access to certification courses and distance learning courses that enable career progression would be another capacity building measure that can be taken up in a phased manner to motivate the Yashoda and reduce drop out rates. Continuing Education, skill up gradation and integration: In the future, this critical support mechanism will be integrated into the NRHM process and scaled up to other parts of the state and health facilities. In turn, their capacity building activities need to be given an organized structure under the state training mechanism such as SIHFW or another appropriate institutional mechanism.

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4.1) Preparation is required for training of Yashoda:

• Identification of trainers: The trainers will be identified from among the medical and nursing staff of the hospital, the nearest nursing college, and ANM training school. Nursing staff and experienced ANM should be used as core trainers.

• Hold one common meeting with the facilitators/trainers/resource persons beforehand

so they understand the overall requirement of the program and the contents. • Provide them with an overview of Yashoda concept note and explain the expected

roles and responsibilities of Yashoda. • Make decisions on venue, food, hand out materials, training aids and other logistics

arrangements. • Get the necessary budget approved and government letter to concerned person for

participation. • Have core trainers prepare training schedules for their respective districts.

4.2 Development of trainer’s manual/facilitator’s guide: • All the training materials will be developed under the guidance of competent technical

expert and other partners at the State level (SIHFW, Medical college/Nursing college any other specialized agencies)

• All the training and educational materials will be translated into the local language • State appropriate adaptation will be made as per their requirement • The methodology of training at each level has to be participatory and practicum based • Teaching aids should be made appropriate to the content and the methodology. 4.3. Handbook/flipchart for the Yashoda: Keeping in mind that Yashoda is a non –clinical support worker, the training methodology and materials should find a balance between technical and non technical input for enhancing knowledge and skills. For example, counselling the mothers on various steps of newborn and mother care after leaving the premises is one of the major roles of Yashoda, which could increase the utilisation of the outreach services substantially. The training methodology should focus on both technical content of the counselling as well as the communication aspects.

The handbook should be a pictorial book with minimal text, using simple terms/language.

• Provide equivalent local terminology for certain difficult technical terms. • Make the pictures culturally appropriate. • A small handbook, flipchart and some leaflets about the newborn care,

breastfeeding, immunization, kangaroo mother care, etc can be provided for routine reference and demonstration to the mothers/ family members. Some IEC materials also can be with her for distribution to the beneficiary mother/ family members and information about the facilities, services and programs.

4.4) Documentation of the training/ training report: The trainings must be well documented to make appropriate changes in subsequent trainings. The documentation should

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clearly mention: relevance of content, usefulness of the training aids and methodology, what additional information could be introduced, etc. The Child health supervisor or the senior nurse will prepare an evaluation of the trainings and analyze them as a means to improve the quality of training. 4.5. Induction training: This is not envisaged to impart detailed knowledge, but designed to orient the newly recruited Yashoda to become confident to work in the hospital context. The induction should be provided within the first two or three days of joining of Yashoda. This will be for a maximum of 3 days and half of the sessions must be conducted in the ward for practical lessons. • Become familiar with the hospital environment, the medical, nursing and other

paramedical staff, labour room/ ward, laboratories and other facilities within the hospital. • Orient them with basic information on newborn care, breastfeeding, supplemental

nutrition, postnatal care of the mothers, counselling on immunization, and possible birth spacing options.

4.6. Hands on training: This is an ongoing and incremental process. The child health supervisors, staff nurses/senior nurses posted at the facility, doctors (paediatrician and gynaecologist) are expected to provide hands on training through demonstration. These sessions should be done on each day during the regular rounds taken up by the doctors and nurses in the maternity wards. The doctors and nurses are expected to provide comments on the progress/competency of the Yashoda to the supervisors during the ward rounds. The child health supervisor or the deputy child health supervisor must note down the feedback/comments/suggestions given by the doctors on performance of Yashoda and take action to ensure quality improvement. • The child health supervisor and/or the deputy child health supervisor should coordinate a

structured interaction between the doctors/nurses and the Yashodas on a regular basis to solve problems and document the key lessons and use it during training.

• Each session has to be repeated twice to involve all the Yashodas, taking into account the duty shifts.

4.7. Periodic Internal Assessment: It is essential to assess the technical knowledge of Yashoda every six months, to gauge whether she has acquired the expected standard to function effectively. This will be a useful input for the refresher training as well. Towards this, the Child Health Supervisor will coordinate the assessment process. This will be conducted by the nurse matron and the ANM training school tutors, preferably by those who had provided the induction training. The assessment tools will be prepared in consultation with the nurse matron at the facility. The assessment tools will target the various components including newborn care, mother care, and breast feeding support, counselling for care after discharge, feeding practices, family planning options, immunization and general support. (See annexure 3 for suggested criteria for assessment)

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In case of poor performance, the hospital competent authorities will decide on strategies for improving the situation. 4.8. Refresher training: This training is planned to be held after 3-6 months of the Induction training, aimed at providing an intensive revision of the technical and practical aspects related to their work. The District level trainers will conduct this training. The Child Health Supervisor (CHS) and the Deputy Child Health Supervisor (DCHS) will also be trainers and coordinate the entire process. 5. Managing the Yashoda Initiative : 5.1. Mentoring and supervision Yashoda supervised and supported by the Child Health Supervisor (CHS) and two Deputy Child Health Supervisors (DCHS) so that for each shift there is one Supervisor of Yashoda. The posting will be at the facility. (See annexure 4 for TOR of CHSs and 4 A for Deputy CHS.). They have the responsibility to mentor Yashoda, provide on the job supervision and support both by way of demonstration, and ensuring the required logistics and administrative support. Nurse/ANM provides technical guidance and feedback on the performance of the Yashoda to the CHSs. In addition, the nurse matron provides administrative support for approval of records and Yashoda incentives submitted by the CHS for further processing. The gynaecologist/paediatrician also provides guidance in technical matters. 5.1) Immediate supervision: The child health supervisors are responsible for:

• Developing duty roasters • Maintaining the attendance and leave registers of Yashoda. • Verifying the daily record sheet filled by Yashoda and cross check with the nursing

/admission register. (See annexure 1 for Yashoda daily reporting format) • Preparing the monthly Yashoda incentive payment sheet and submitting it to the

Hospital superintendent via nurse matron for release of payment and copy to head nurse. This is prepared by the third of every month

• Taking up problems of Yashoda with the concerned authority within the hospital • Preparing the monthly summary sheet for reporting to the Medical Superintendent via

matron and DPMU (hospital manager and District child health manager). (see annexure 5 and 6 for daily task of Yashoda and what she needs to know progressively over a period off time)

• Be responsible for overseeing the general cleanliness of the Maternity ward and use creatively funds for IEC in the ward

• Preparing the indent for consumables and supplies • Monitoring performance of Yashoda in consultation with matron.

5.2) Deputy Child Health Supervisor For ensuring smooth functioning and effective supervision it is proposed to have a Deputy Child Health Supervisor (DCHS) to assist the CHS for effective supervision and mentoring of the Yashoda. While one of the supervisors supervises Yashoda during the

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day, the other supervisor will cover during the evening /night hours. They will share the night duty also.

To have balance of technical and managerial skill mix, it is suggested that the Deputy CHS will be from the Nursing stream, preferably a retired nurse/ ANM/LHV, because of their understanding of the functioning of the health system

5.3). Overall supervision is provided by the ADMO /medical superintendent identified by the CDMO/CMHO. This includes:

• Recruitment and appointment, approval of payment norms, purchase of the supplies and consumables, and disciplinary action and related administrative matters.

• In the NIPI focus districts, the District Child Health Managers will assist the

ADMO/Medical Superintendent in discharging /coordinating all the above functions and day to day operations.

• Districts other than the NIPI focus districts, the Hospital Managers in the respective

facilities will carry out the same functions. 5.4): Flow of information on Yashoda performance from the facility to the State level. While Yashoda work is confined to the hospital, the input she provides is expected to bring significant increase in terms of, the duration of the stay of the mother at the facility, percentage of mothers initiating breast feeding within one hour birth, percentage of mothers immunizing their children and percentage of newborns weighed. This information is captured by the Child Health Supervisors (CHS) at the facility level by collecting, collating and analyzing the Yashoda daily reporting format, needs to be shared with wider audience at the district and the state level for understanding the value addition that Yashoda interventions brings to JSY and make further modification or improvements in the intervention. Therefore it is suggested that the CHS on completing the analysis, will apart from sharing the information within the hospital with the nurses and doctors, will also send it to the NIPI District Child Health Manager or the District Program Manager (DPMU), to be forwarded to the State NRHM Mission Director, with copy to the NIPI State program Manager. This step is critical for embedding the intervention within NRHM processes from the starting point. 5.5). Informal community monitoring of quality care at the facility-Involving Clients: Local Women’s Visiting Group : Several potential outcome are expected out of the Yashoda interventions including longer duration of stay of mothers, more mothers initiating immediate and exclusive breast feeding, improved immunisation, increased number of mothers get informed on basic newborn care, nutrition and feeding practices, increased utilisation of outreach services such as immunization, referral services etc in those villages that utilise the services of the hospital. The intervention is monitored at different levels in the hospital for achieving these expected outcomes.

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It is recommended that, involving the community in informal monitoring of the services periodically will being value addition to the process by way of enhanced ownership and informal promotion of hospital services. This could be facilitated by establishing a process, which engages a group of local women to visit the hospital periodically and interact with the mothers, Yashodas and the nurses on the various issues related to care given to newborn and the mothers. This will give them a chance to see the hospitals by themselves, observe the improvements, make their suggestions in the visitor’s register, thereby contributing to promoting improving quality of services. While this group does not have any legal position, they carry the good will of the community and could contribute to enhanced community appreciation of the efforts of the hospital. The District Hospital authorities could explore establishing this mechanism by inviting a mix of women Panchayat members/self help groups/village sanitation committee, from the villages to visit the hospital periodically. This event could be facilitated by the District Child Health Manager by providing the appropriate budget and logistics arrangements. 6. Institutional mechanism: The fund for the Yashoda initiative per district is placed with the DHS under the State child health plan based on the number of deliveries conducted in the district hospital in the previous years. Estimated budget for a period of six months gets transferred to the RKS, who in turn disburses the Yashoda incentives and salary of the Child Health Supervisors directly. RKS submits quarterly utilization certificates to DHS. The payment mechanism for Yashoda is detailed out in section 3.8 above. 6.1. Functional Linkages of Yashoda within the Institution It is important to note that though Yashoda is not a regular employee of the system, she has definite roles and district linkage with several of the established hospital system for effective functioning. The CHSs and the nurses should ensure that these linkages are facilitating efficient functioning of Yashoda that can result in improving the quality of care for newborn and the mother at the facility.

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Yashoda gets both administrative and logistics support as well as technical support from the hospital team. On day to day basis, she supervised and monitored by the CHS and the nurse/matron. The CHSs are responsible for all the administrative and logistics support and supportive supervision to the Yashoda and acts as mentor. The nurses provide technical guidance to Yashoda during regular ward rounds, give feedback on Yashoda performance and support the supervisor on the administrative aspects. The medical officers (Paediatrician and Gynaecologist) support Yashoda capcity building through hands on training and feedback during ward rounds on a day to day basis. The Medical Superintendent and DPMU(through the hospital manager and the District Child health manager) together provide overall supervision and management support to the Chief Medial Officer.

Yashoda

CHS & Dy CHS

Matron/Nurse

M.S/ ADMO-Med

CMHO

MOs- Ped/Gyn

CMHO: Chief Medical and Health Officer MS: Medical Superintendent ADMO: Assistant Medical Officer DPMU: District Project Management Unit DHM: District Hospital Manager DCHM: District Child Health Manger MO: Medical Officer (Paediatrician & Gynaecologist) CHS: Child Health Supervisor Dy. CHS: Deputy Child Health Supervisor

DHM

DCHM

DPMU

17

Annexure: 1

BCG

OPV

Vaccinatio

Any

prob

lem

w

ith M

othe

r

Name of the

Dat

e &

Tim

e of

dis

char

ge

Yashoda Daily Reporting Format

Dat

e &

time

of

Adm

issi

on

Dat

e &

time

of d

eliv

ery

sex

of b

aby

Nam

e &

Addr

ess

Wei

ght o

f ba

by

Name of the Hospital

Sl n

o

age

Parit

y

BPL

Initi

atio

n of

BFAn

y pr

oble

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Annexure 2 Budget calculation for compon ents of Yashoda incentive . Detailed Budget for Yashoda Intervention at District Hospitals under NIPI Case scenario District Hospital 750 deliveries a month

A. Honorarium to Yashoda : Units Unit cost (in Rs)

Total (in Rs)

Estimated No of Deliver ies every month 750 Estimated No of Deliveries Per Day 25 Estimated No of Yashodas per day (@ 1 for 5 deliveries X 3 shifts) 15 Addition pool of reserve Yashodas (20 % extra) 3 Remuneration of Yashoda (Rs. 100 per baby & mother cared) 750 100 75000 Remuneration per yashoda per month (Average) 18 4167 Remuneration for Yashodas (annual) 900000 Sub-total remuneration to Yashodas 900000 B. Apron, slipper & working arrangement: Apron @ Rs. 600 per Yashoda for two sets 18 1200 21600 (Biannual @ Rs. 600 with the remunerations) Slippers @Rs 50 per Yashoda (1 pair every 6 months) 18 100 1800 (Biannual @ Rs. 50 with the remunerations) Plastic Chairs for Yashoda @Rs.300/chair x 6 chairs 6 300 1800 Cupboards for each district hospital for storing aprons etc. 1 5000 5000 Badge and bag 18 150 2700 Sub-total accessories for Yashodas 32900 C. Training of Yashoda C.1. Training of Trainers No. of Participants (3 Trainers from each district) 3 5000 15000 (Doctor-1, Nurse 1, ANM teacher/ 2nd nurse -1) (Duration - 3 days at state level) C.2. Training of Yashoda (Module -1 & Module- 2 at one month interval) Duration - Two Days/ Module (Total 4 days) No. of Yashoda to be traine d 18 Venue- ANM Training School Duration- 2days each module (total 4 days) Training Materials 18 150 2700 Stationary (Pad, pen, marker etc.) 18 50 1800 Food & snacks for the participants 18 100 7200 Trainers honorarium (3 trainers x2 days x 2 modules) 6 500 6000 contingency @ Rs 1000/ district lump sum 1000 Sub-total Training for both Modules 18700 C.3.Follow up training Duration - One day on 5th month No. of Yashoda to be trained 18 Venue- ANM Training School Participants Food & snack for one day 18 100 1800 Trainers honorarium(3 trainers 1 day) 3 500 1500

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Contingency @ Rs. 250/district lump sum 250 Sub-total follow up training 3550 C.4. Assessment o f the Yashodas After 6 months to assess the effectiveness of the training and need for revision No. of Yashoda to be assessed 18 Venue- ANM Training School Duration- 1 day Faculty honorarium (2 faculty) 2 500 1000 contingency (@ Rs. 250) lump sum 250 Sub-total assessment of Yashodas 1250 C.5. Educational material for Yashodas (Flip chart and booklet for counselling mothers) Per district hospital 10 sets (covering all shifts and some extra) 10 500 5000 Total for training of Yashodas (C1+C2+C3+C4) 39750 D. Child Health Supervisor(s) Contingency @ Rs. 2500 per month 1 2500 30000 Training of the supervisors @ Rs.10000/ Supervisor 2 10000 20000 (at the identified Medical College - Maternity ward & Newborn ward ) Working arrangement for supervisors 1 10000 10000 (chair, table, storing space, etc) Sub-total for Child Health Supervisors 60000 E. Consumables with the Yashodas/CHS and Ward IEC @ Rs.1000 per district hospital per month with the Supervisor 1 1000 12000 (for day-to-day consumables for cleaning & maintenance)

Fresh white sheets, Rubber Cloth, spare clothes for newborn etc

To be provided by RKS

@ 30,000 per District Hospital for Ward IEC Support 1 30,000 30,000 Sub Total 1,80,000 F. Mentoring & Training incentives for the Head Nurse & RCH Nurse* For Head Nurse @ Rs. 1500 per month (Rs.1250 -1500) 1 1500 18000 For RCH Nurse @ Rs. 1000 per month( 750 -1000) 1 1000 12000 Sub Total 30,000 G. Communication modality for emergency * 1 4200 4200 (Mobile phone for informing the nurse/ doctor during emergency need) (Monthly Rs 100 talk time) (*To be started after 6 months- once the system is in place) H. Recruitment process of Yashodas 7500 7500 (Includes advertisement and selection process) Total annual expenditure for Yashoda scheme at one district hospital 1258100 Cost per del ivery for Yashoda scheme 139.8

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Additional plan for patient counselling and education, Salaries of Supervisors H. IEC/BCC for the mothers & family members ** 2 35000 70000 (about Newborn, child health & maternal care) (Installing TV/LCD screens with centralized control unit) I Salaries of Child Health Supervisors ** One child health supervisor @ Rs. 10000/ mon 1 10000 120000 Two deputy Child health supervisor @ 7000/mon (rangeRs. 5000-7000) 2 7000 168000 Total Additional Cost 3,58,000 (**Additional cost from the Untied fund at district level and Enabling Mechanism)

* Matron and RCH Nurse have to take additional workload to be engaged in details of the Yashoda process including Supportive Supervision and Training.

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Annexure : 3

Suggested Criteria for Assessing performance of Yashoda 1. General: -Attendance, punctuality, personal cleanliness; -Alertness in the ward -Ability to manage the crowd in the wards -Ensuring cleanliness in the ward including the toilets

2. Behavior: -Group dynamics- working with other Yashoda-Peers -Friendliness and interaction with the women admitted in the ward and their family. -Interaction with the nurses and other hospital staff

3. Technical knowledge: -Post partum care of mother -Assisting in breast feeding -Basic care of the new born and danger signs -Immunization

4. Skills acquired: -Wrapping the baby, temperature reading, cord care, -Assisting in breast feeding -Counseling skills

5: Communication Skills: -Ability to communicate verbally to the mother and her family -Communication with other Yashodas, supervisors and nurses. -Ability to clarify doubts to mother and appropriate use of the BCC/IEC materials while communicating with the mother

6. Reporting: -Regularity, clarity of reporting and comprehensiveness.

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Annexure 4:

Terms of reference: Child Health Supervisor (CHS)

Primary role of CHS is to supervise and coordinate the day-to-day activities of the ‘Yashoda’ for smoother service delivery at the district hospitals. Towards that she will have logistics, managerial, planning and supervisory duties. The child health supervisor will coordinate and liaise with the hospital staff and authorities, Rogi Kalyan Samiti, DPMU and the NIPI State program officers for the various functions.

For ensuring smooth functioning and effective supervision it is proposed to have supervisor; Child Health Supervisor (CHS). The CHS provides overall supervision to Yashoda with assistance from the Deputy Child Health Supervisor. The Deputy supervisor will generally cover the evening shifts. However, the CHS will also work one week in a month in the night shift.. To have balance it is suggested that one of the supervisors should be from the Nursing stream and the other from the social science/ social work background. Since the CHS has more coordination, logistics and managerial role and less technical support role, she could be drawn from the social sciences stream. Many of the tasks are common, but some of the responsibilities are specific as per the technical expertise. Keeping the gender and cultural sensitivity in mind, it is essential to fill these positions with female candidates since their role demands frequent movement within the labour ward to supervise the work of Yashoda and provide support to breast feeding. It is essential that the CHS and DCHS are selected prior to the selection of Yashoda, to assist the hospital team in the Yashoda selection and orientation.

Roles and responsibilities of CHS Coordination related:

• Play an active role in the selection of Yashoda and in preparation of their orientation.

• Plan and develop Yashoda duty roaster taking into account: -Number of Yashoda required for each shift

-ensuring a pool of reserve to avoid any gap in service by planning for potential turn over, absenteeism, and leave.

• Ensure correct maintenance of the Yashoda daily report chart and verify the same with the records of the nurse.

• Collate and analyze the Yashoda reports on monthly basis and discuss with chief nurse/ADMO for required action.

• Prepare the attendance and payment sheet and coordinate with the hospital authorities /RKS for timely release of Yashoda payment every month.

• Develop and maintain Yashoda performance assessment form and submit on a monthly basis to the Medical Superintendent via matron, and copy to District Child Health manager and Hospital Manager.

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• Prepare indent for the various materials and consumables required. • Coordinate timely procurement and distribution of apron/sari/ slippers/counselling

materials and ensure their appropriate use by Yashoda. • Coordinate the logistics arrangement related to all the trainings. • Coordinate with appropriate authorities for ensuring timely release of Yashoda

incentive and appropriate support facilities for Yashoda.

Yashoda capcity building related: • Function as Yashoda mentor and provide guidance for better quality care for the

mother and newborn. • Discuss with nurse and doctor on a regular basis to understand the performance of

Yashoda and take corrective action. • Ensure Yashoda gains counselling skills to communicate effectively on basic

newborn care messages to the mothers and her family members. • Monitor and guide Yashoda for initiating early and exclusive breast feeding,

providing information complementary feeding for the baby and mother’s nutrition after leaving the facility.

• Develop a quarterly Yashoda training schedule detailing orientation, hands on training, continuing education etc.

• Coordinate with the Medical/ nursing staff and DPMU for all the training including orientation and refresher training of the Yashoda.

• Coordinate with the NIPI Program officers for the preparation of appropriate training materials.

• Develop an appropriate appraisal mechanism for Yashoda. • Ensure setting up an Emergency contact mechanism within the hospital with a

standard protocol for the Yashoda to be followed in cases of emergency identified with any baby or mother for urgent clinical intervention/ appropriate action to be taken by the medical/ nursing staff.

• Support the District hospital and Child Health Manager in the preparation of district child health plan.

• Whenever possible interact with the ASHAs from community escorting the pregnant mothers for sharing the knowledge related to the MCH care, services.

• Establish system for motivating and building the team sprit of Yashoda. Suggested Qualification, Experience and Remuneration:

The state can make the final decision about the qualification and payment. • Post graduates from Social science/social work /nutrition/ home science discipline

with public health training or with adequate experience in MCH field in Government or NGO sector. Retired persons with good track record may also be considered.

• Nursing graduates, ANMs with adequate experience in MCH field can also be considered.

• Should have commitment & dedication towards maternal and child health services, effective communication skills, leadership qualities and pleasant personality.

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Compensation • Monthly consolidated compensation of Rs.10000/- plus conveyance, communication

and office expense of at least Rs.2500/- per month is suggested.

Annexure 4A: Terms of reference Deputy Child Health Supervisor (DCHS) For ensuring smooth functioning and effective supervision it is proposed to have a Deputy Child Health Supervisor (DCHS) to assist the CHS for effective supervision and mentoring of the Yashoda. While one of the supervisors supervises Yashoda during the day, the other supervisor will cover during the evening /night hours. They will share the night duty also. To have balance of technical and managerial skill mix, it is suggested that the Deputy CHS will be from the Nursing stream, preferably a retired nurse/ ANM/LHV, because of their understanding of the functioning of the health system. The DCHS will provide vital support to the CHS to establish the Yashoda system. Many of the tasks are common and shared by both; however, the deputy CHS will be responsible for the following. • Develop a handbook/ operational guidebook for Yashoda, for the do’s and don’t for

handing the newborn and general functioning within the hospital premises. • Ensure development of protocol to be followed by the Yashoda while delivering the

essential services. • Collate and analyze the Yashoda reports on monthly basis and discuss with chief

nurse/ADMO for required action. • Assist the CHS for preparing the attendance and payment sheet and coordinate with

the hospital authorities /RKS for timely release of Yashoda payment every month. • Develop an appropriate appraisal mechanism for Yashoda- Develop and maintain

Yashoda performance assessment form and submit on a monthly basis to the Medical Superintendent via matron, and copy to District Child Health manager and Hospital Manager.

• Provide technical inputs to Yashoda skill up gradation, especially hands-on training. Assist in planning a quarterly Yashoda training schedule detailing orientation, hands on training, continuing education etc.

• Function as Yashoda mentor and provide guidance for better quality care for the mother and newborn.

• Discuss with nurse and doctor on a regular basis to understand the performance of Yashoda and take corrective action.

• Monitor and guide Yashoda for initiating early and exclusive breast feeding, providing information complementary feeding for the baby and mother’s nutrition after leaving the facility.

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• Support Yashoda by coordinating with the hospital staff for maintenance functions of the ward; especially related to cleanliness of the ward and toilets and availability of water without interruption.

• Motive Yashoda to function in a team and monitor that they function well as a team in a coordinated manner.

• Provide Yashoda with information on village level service providers (ASHA, ANM, and AWW), immunization schedules, referral services and contact/focal points to approach in case of need when the mother returns to the community.

• Build Yashoda capacity in a phased manner for maintenance of monitoring chart for the baby and mother about vital parameters (temperature, respiratory rate of both newborn and mother and pulse rate of the mother) and help her to resolve problems if any.

• Coordinate with the NIPI Program officers for the preparation of appropriate training materials.

• Ensure setting up an Emergency contact mechanism within the hospital with a standard protocol for the Yashoda to be followed in cases of emergency identified with any baby or mother for urgent clinical intervention/ appropriate action to be taken by the medical/ nursing staff.

Suggested Qualification, Experience and Remuneration:

The state can make the final decision about the qualification and payment. DCHS: • Retired nurses, ANMs, LHVs with adequate experience in MCH field and good track

record are the preferred candidates for this position. • Should have commitment & dedication towards maternal and child health services,

effective communication skills, leadership qualities and pleasant personality. Must be willing to work in evening and night shifts.

Compensation • Monthly consolidated compensation of Rs.7000/- per month is suggested.

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Annexure 5: Yashoda tasks:

Frequency Activities Every 2-4 hourly during the shift

• Check and assist starting breastfeeding within 30 min after delivery

• Assist the mother to keep the baby clean, dry and well covered

• Check that the ward is not crowded • Check if any new pregnant woman is

admitted and assist in registration and bed preparation.

• Check breastfeeding of every newborn and assists mother for successful breastfeeding

• Check the temperature of the baby and record

• Ensure that the newborn is not given any feed other than the breast milk.

• Check the pad of mother for bleeding • Check the temperature and general

status of mother• Record the parameters for mother

Daily routine activities

• Take over from the earlier shift • Interact with the Child Health

Supervisor about the progress and problems

• Accompany the doctor/ nurse during clinical rounds

• Follow the instructions given by nurse/ doctor

• Check the cleanliness of the ward and toilet and take necessary steps to ensure cleanliness

• Complete the reporting sheet with information on each delivery including still, birth and verify with the nurse’s register for accuracy.

• Handover to the next shift Yashoda about each of the babies and mothers

• Check if the form for birth registration is filled properly for each live birth.

• Ensure immunization of the babies before discharge

• Check breastfeeding status of each newborn

• Basic assessment of the newborn and inform if any problem noticed

• Counsel mothers on breast feeding and basic newborn care.

•

• Ensure mothers and their family members are counseled about mother’s diet, rest, and contraception.

• Basic assessment of the mother for problems

• Assist mothers in getting the JSentitlement

Incase of • Inform the nurse/ doctor • Take necessary basic steps as • Follow the instructions of the nurse/

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emergency • Inform the Child Health Supervisor

demonstrated during training doctor

For administrative/ incentive/ logistics related issues

• Inform the Child Health supervisor and follow the instructions

• May contact the Medical Superintendent, Hospital Manager or District Child Health Manager depending on the matter

•

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Annexure 6.

Incremental technical input for yahsoda:

After a week At the end of the first month By the third month • Hospital staff and services, and

facilities including wards, labor room, OT, Laboratory & admission procedure.

• Understand about their roles and responsibilities

• Be familiar with the rules and regulations of the hospital.

• Be familiar with some of the essential aspects of newborn care as per the initial orientation.

• How to assist the mother in admission, registration, and bed preparation.

• Basic preparation of the pregnant woman before she goes into the labor room.

• Basic newborn care: - Temperature maintenance and

wrapping the baby appropriately.

- cord care - Keeping the baby dry, clean

and warm. • Basic care of the mother -change the pads -diet • Checking temperature of the

baby and mother • Counting respiratory rate • Support he mother to start

breast feeding. • When to call the nurse or

doctor for assistance.

• Acquire competency in assisting and counseling for breast feeding

• Address breastfeeding problems

• Identify danger signs in the new born -hypothermia identification and care

-respiratory distress -jaundice

• Care of the low birth weight baby

-feeding low birth weight babies

-kangaroo mother care • Counsel the mother -about care during immediate post delivery period -diet, rest, contraception • Advice at discharge - information on contact person

for follow up and in emergency - immunization , exclusive breast

feeding, supplementary feeding

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