Keyur Sorathia
Indian Institute of Technology, Guwahati

Minal Jain
Indian Institute of Technology, Guwahati

Mannu Amrit
Indian Institute of Technology, Guwahati

keyur@iitg.ernet.in

minal@iitg.ernet.in

m.amrit@iitg.ernet.in

ABSTRACT
Assam, having highest maternal deaths in India demands attention to investigate the problems and provide appropriate solutions. We present a qualitative user study conducted with ASHAs (Accredited Social Health Activist) and ANMs (Auxiliary Nurse Midwife) in Amingaon, Kamrup District, Assam. The study aimed at investigating existing problems faced by ASHA members and ANMs', their work environment, their role in safe and healthy motherhood, relationship with pregnant women (PW) and family members, technology literacy and opportunities for Information Communication Technology (ICT) interventions to empower maternal health scenario. Two sub-centers (SC), one anganwadi center, one primary health center (PHC) and one community health center (CHC) were visited and observed. 6 one-to-one on-field interviews were conducted with ASHA members and ANMs. This paper presents research insights, findings and analysis of conducted on-field user research. It identifies problem & information gaps and proposes opportunities for technology and design interventions.

They are mostly ignorant of any government schemes or health care measures during pregnancy. We intend to identify the opportunities for design interventions in the entire system with an aim to improve maternal and child health and ensure a safe and healthy motherhood.

2. BACKGROUND 2.1 About NRHM, PHC, Sub Centre
As stated in the NRHM (2005-2012) Mission document, the National Rural Health Mission (2005-12) seeks to provide effective healthcare to rural population throughout the country with special focus on 18 states, which have weak public health indicators and/or weak infrastructure. Its major aims include reduction in Infant Mortality Rate (IMR) and Maternal Mortality Ratio (MMR), universal access to public health services such as women’s health, child health, water, sanitation & hygiene, immunization and nutrition, prevention and control of communicable and non-communicable diseases, including locally endemic diseases, access to integrated comprehensive primary health care, population stabilization, gender and demographic balance, revitalization of local health traditions and promotion of healthy lifestyles. PHC is the first contact point between village community and the Medical Officer. [1] It acts as a referral unit for 5-6 sub-centers. The essential functions of the PHC include medical care, MCH including family planning, safe water supply and basic sanitation, prevention and control of locally endemic diseases, collection and reporting of vital statistics, education about health, training of health guides, health workers, local dais and health assistants and basic laboratory services. The Sub-Centre is the most peripheral outpost of the existing health delivery system in rural areas and first contact point between the Primary Health Care system and the community [1].

Keywords
Maternal Health, ASHA, ANM, Pregnant Women, Assam

1. INTRODUCTION
Tucked away in the northeastern region of India, the state of Assam presents various challenging problems in the field of health. The reason behind most of them is the lack of knowledge or awareness amongst the general public and lack of proper infrastructure and manpower. In the present context, Assam records one of the highest maternal mortality rates in India. Before the inception of the National Rural Health Mission in 2006, the mother’s and infant’s health was in a grim state. With NRHM’s inception and the Accredited Social Health Activists (ASHA) program, the efficacy of the intended health schemes has improved. ASHA members are shouldered with the responsibility of taking care of the pregnant women all through their pregnancy and childcare period. Despite the efforts, the maternal mortality rate is high and very less women are able to enjoy a happy and healthy motherhood.
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healthcare. She is responsible for maintaining records like the village record register, sub center OPD register, UIP master register, family planning register, eligible couple register, MCH master register, stock ledger (medicine/ kits/instruments/equipment/ furniture) register, death register, register for recording minutes of S/C Management Committee meeting and accounts register for keeping records of Untied and Maintenance fund. [4]

2.3 Government Schemes 2.3.1 Mamoni Scheme
Mamoni a scheme launched under ‘Assam Bikash Yojana’ for all pregnant women. During the First Registration, the pregnant women are given Mamoni, a book on antenatal, natal and postnatal care. During her 2nd ANC and 3rd, the pregnant women is given an account payee cheque of Rs. 1000/- in two equal installments as a nutritional support. [5]

Figure1: Moriyapati Health Sub Center A, Amingaon, Kamrup, Assam They are established on the basis of one sub-center for every 5000 population. Sub-Centers provide services in relation to maternal and child health, family welfare, nutrition, immunization, diarrhea control and control of communicable diseases programs.

2.3.2 Janani Suraksha Yojana (JSY)
Janani Suraksha Yojana (JSY) is a safe motherhood intervention under the National Rural Health Mission (NRHM) being implemented with the objective of reducing maternal and neo-natal mortality by promoting institutional delivery among the poor pregnant women. JSY integrates cash assistance with delivery and post-delivery care. According to the scheme, in rural areas, all mothers irrespective of age, birth order, or income group (BPL & APL) will get cash assistance of Rs. 1400/- in one go at the time of delivery. [6]

2.2 About ASHA, ANM
According to the NRHM, an Accredited Social Health Activist (ASHA) is responsible for a population of 1000. She is the first port of call for any health related demands the population, especially women and children, who find it difficult to access health services. She should have a formal education up to class eight. The ASHAs receive performance-based incentives for promoting universal immunization, referral and escort services for Reproductive & Child Health (RCH) and other healthcare programs, and construction of household toilets. They counsel women on birth preparedness, importance of safe delivery, breastfeeding and complementary feeding, immunization, contraception and prevention of common infections including Reproductive Tract Infection/Sexually Transmitted Infections (RTIs/STIs) and care of the young child. ASHAs mobilize the community and facilitate them in accessing health and health related services available at the Anganwadi/sub-center/primary health centers. The guidelines already issued on ASHA envisage a total period of 23 days training in five episodes. After a period of 6 months of her functioning in the village it is proposed that she be sensitized on HIV / AIDS issues including STI, RTI, prevention and referrals and also trained on new born care. [2] ASHA is an honorary volunteer and does not receive any salary or honorarium. However ASHA could be compensated for her time in the situations of her training both in terms of TA and DA, for participating in the monthly/bi-monthly training and under different national programmes for undertaking specific health or other social sector programmes. [3] The Auxiliary Nurse Midwife (ANM) is responsible for the sub center. She holds weekly/fortnightly meeting with ASHA, and provides on-job training by discussing the activities undertaken during the week/fortnight and provides guidance in case ASHA encounters any problem. She ensures that during the training ASHA gets the compensation for performance and also TA/DA for attending the training schedule. She motivates the pregnant women for coming to the Sub-Centre for initial check-ups and taking full course of Iron and Folic Acid (IFA). She gives them advice on

3. METHOD
We started the project with extensive literature research to understand the complete system of healthcare distribution at all the levels of the hierarchy. Roles, incentives, environment of all the people involved were studied. Categories of people who needed to be interviewed were identified and questionnaires were prepared. We then carried the research forward with visits to the Sub Center at Amingaon. In the initial visits, we carried out fly-on-the-wall observations of the sub centre operations. This was followed by detailed discussions and interviews with the ANM and the ASHA members. Their work dynamics and ecosystem were studied and understood. A few pregnant women visiting the sub-center were also interviewed. The interviews of ASHA and ANM focused on the following: General Demographics - their age, residence, working since how many years, family background. Motivation - motivation behind joining the job. Training - when the first training was given, for how long, what was taught, methods of teaching, reference material. Record Maintenance - what records need to be maintained, how are they maintained, how effectively are they maintained. Work Routine - what work has to be done in the entire day, what are the different things taken care of, what is the work environment, how exhausting it is. Monetary Benefits - how much money is given for the work, how is it disbursed, what procedure is followed. Mobile Phone usage - how much technological exposure is there, what features are used in a mobile phone, how efficiently it is used.

In the later stage the Community Health Centre where the ASHAs are imparted training was visited. The block program manager was interviewed to know more about the training sessions.

3.1 Sub centers and CHCs
Moriyapati Health Sub Center A, Amingaon, Kamrup was visited frequently for observations. It has a population of 10 thousand under its purview. It comprises of a small room and a narrow waiting area. Sub-center B which has a population of 5 thousand is situated in the adjoining room. Sub center A has two Auxiliary Nurse Midwives and a multipurpose worker. It is equipped with basic kits for check-ups and tests. Walls are covered by NRHM boards and posters talking about different schemes and tips.

educated till 5th standard and had taken care of 40 pregnant women till date. She was an ASHA since 6 years and had a population of 1560 under her and 18 pregnant women currently. She was proficient in assamese, bengali and hindi and was given the best ASHA award by the state government. Each one of them was given a mobile phone by the government but its usage was limited to calling.

4. FINDINGS AND IMPLICATIONS TO DESIGN 4.1 Improper and inconsistent training
Trainings were held at Bishnuram Medhi Community Health Centre, Hajo which was 1.5 hours away from the sub-centre. Every ASHA, after her joining is supposed to be given a training of 21 days where she is taught about the different aspects of pregnancy and healthcare. It also comprised of lessons in vaccination, cure, prevention and symptoms of different diseases. As gathered from the contextual interviews, training for ASHA members were not held regularly and were not very effective. As described by a few ASHA members, the training was held after a year or more of their becoming the ASHA. Before the training, they worked purely on referrals from senior ASHAs or ANMs. Thus, in this case the training was not of any use to them. As described by one of the clerks working at the CHC, the training was held once in 12 or 18 months. The training room was equipped with a white board. The block program manager mentioned that the trainings comprised of teaching with the white board, dramatization and evaluation after every 3-4 hours. However, very less ASHA members agreed to have taken any notes during the class or referred to them later on. Many of them took trainings for granted and relied on practical knowledge or peers for any information. Systems that can impart training to the ASHA as and when required can be installed at places that are in their easy reach like the sub-centre.

The Bishnuram Medhi Community Health Centre, Hajo is situated at a distance of 23.8 kms from the Moriyapati Health Sub Center A. It is where the ASHA members are given training. There is a small room for this purpose. The doctors train certain resource people who in turn impart the training.

3.2 ASHA and ANM profiles

4.2 Physically exhausting work
Figure 2: Interviewing ANM at the Moriyapati Health Sub Center A, Amingaon, Kamrup Two ANMs (ages 36 and 50) were interviewed. Both of them are 10th grade pass and are proficient in assamese with knowledge of english and hindi. Both of them possess phones but their usage is limited to calling and a little messaging. They have been working since 2-3 years at the sub center. They give nutritional health tips to the pregnant women and are responsible for basic check-ups and tests. They receive training time to time and maintain records of all the people in the purview of the sub center. Four ASHA members were interviewed. The first one was qualified till 10th grade and was an ASHA since two years. She had taken care of 40 pregnant women till date and had a population of 1500 under her and was proficient in assamese, hindi and bengali. The second one was also an ASHA since 2 years and had a population of 520 under her with 6 pregnant women currently. The third one was educated till 4th grade and knew assamese and a little hindi. She had a population of 550 under her with 6 pregnant women currently. She was an ASHA since 6 years. The fourth one was also ASHA members have to go door-to-door for reminding their patients about their impending check-ups and immunization. They also have to take care of their medicines and general health for which a number of visits have to be paid. Also, the ASHA accompanies the pregnant woman for all check-ups and tests to the hospital and the sub-centre. There is a long waiting time at these places which add up to the misery. Interventions can happen at this place to effectively utilize the waiting period in imparting knowledge and empowering the pregnant women, making them less dependent on ASHA. Also, systems that can eliminate the need for ASHA to visit each and every household personally to remind can be designed.

4.3 Cumbersome and redundant record maintenance
The ANMs keep a register to maintain the records of the pregnant women. 2 copies are made (1 submitted to the PHC).The register has details like date of registration, reg.no., name of pregnant women, age, sex, L.M.P (Last Menstruation Period), E.D.D (Expected Delivery Date), name of husband, address, 1st ANC (Antenatal Check-up), 2nd ANC, 1st TT, 2nd TT, 3rd TT, TT

Booster, ASHA in-charge. They are also required to submit a monthly report of the sub centre (printed 9 page form), report of the mamoni receivers and the immunization report to the PHC. And few weekly reports like those for Syndromic Surveillance about fever, jaundice, stool etc., Immunization report are also submitted. They maintain a hangar with month-wise sorted health cards. They also have a community self-monitoring tool that gives them a quick glance of the details of the pregnant women. Some ASHA members also maintain the record of all the pregnant women for their convenience. Others convey all the details verbally to the ANM.

Many pregnant women, at the time of delivery, go to their maternal homes and get delivered there. This is another cause for maternal deaths. The government has launched the JSY scheme specifically to encourage institutional deliveries. There is a need to motivate pregnant women to go for it.

4.6 Less usage of technology
Government has provided mobile phones to each ASHA member for her day to day job. However, the research shows that they are not much aware of its features and only know how to make calls. Many of them do not address to missed calls. Even the pregnant women are not technologically aware. They only use phones to make or receive calls. This shows that a very simple solution probably using voce based input/output would work.

4.7 Lack of information amongst pregnant women and hence high dependence on ASHA
Pregnant women, as gathered from the research, are highly dependent on the ASHA members for their day-to-day activities. They have no knowledge of proper diet, exercises, healthcare and pregnancy. They also follow the ASHA blindly with regard to the medical check-ups and tests. ASHA is their first port of contact for any information. This dependence can prove dangerous for the pregnant women. There is thus a need to impart education to the pregnant women and make them independent. Figure 3: Records maintained by ASHA Due to improper or no records with the ASHA, chances of missing out the check-ups of the pregnant women increases. Also, due to the same record being kept and maintained separately by ASHA, ANM and PHC, the redundancy increases. There is a need to have a record maintenance system that can be accessible at all levels.

5. CONCLUSION AND ONGOING WORK
The research has been carried forward and we are currently in the process of conducting discussions and interviews with pregnant women to try to understand factors such as family dynamics, awareness of government schemes, diet and exercises, problems faced, dependency on ASHA etc. We’re also trying to understand the working dynamics of the Tolaram Bafna district civil hospital through fly on the wall observation and discussions with the gynaecologist on duty. After completing this study and research, further use cases would be prepared and brainstormed upon before finalizing upon a solution. We would then proceed with prototyping and evaluation of the finalized idea.

4.4 Long and cumbersome process of money redemption
Money redemption for ASHA members is a tedious task. To claim her money she has to submit a form along with the photocopy of the medical card to the ANM to get her signature and seal. The doctor’s signature is also required. It is then submitted to the PHC where the amount is transferred to her account. The amount of money given leaves no motivation amongst the ASHA members. She gets a meager amount of 400 after the institutional delivery, 200 after the first injection and 250 after the measles vaccine. ASHA members are often discouraged by their family members for the work due to the low income it offers. For the pregnant women, none of the interviewed ones had ever got any money under the mamoni scheme. Many were aware of the scheme but very complacent. Only the amount of 1400 that is paid directly from the hospital under the JSY scheme at the time of delivery was given. Apart from this, no other monetary benefit reached them. Belonging to economically weak sections of the society, these people hence could not take care of the health of the mother before and after pregnancy, thereby leading to maternal deaths.

6. REFERENCES
[1] Indranee Dutta and Shailly Bawari, Health and Health Care in Assam, a status report, Centre for inquiry into health and allied schemes 2007 [2] About ASHA [online]. Available from http://mohfw.nic.in/NRHM/asha.htm#abt [Accessed 12th August 2012] [3] Compensation to ASHA [online]. Available from http://www.mohfw.nic.in/NRHM/RCH/guidelines/ASHA_guidelin es.pdf [Accessed 12th August 2012] [4] Auxiliary Nurse Mid-wife [online]. Available from http://mohfw.nic.in/NRHM/stakeholders.htm#anm [Accessed 12th August 2012] [5] State Funds [online] Available from http://www.nrhmassam.in/state_pip/state_funds.pdf [Accessed 18th August 2012] [6] Janani Suraksha Yojana (JSY) [online]. Available from http://www.nrhmassam.in/jsy.php [Accessed 12th August 2012]

4.5 Need for motivation amongst the pregnant women for institutional delivery