There has been a decline in the childhood and neonatal mortality parameters of India over the years, but this reduction is comparatively slower in the neonatal group [1,2]. In an attempt to address the issue of high neonatal mortality, Government of India released Home Based Newborn Care (HBNC) guidelines in 2011; and ASHA workers were mobilized for providing maternal and immediate newborn care. The guidelines were revised in 2014 to include expectations for ASHA to make timely institutional referrals during pregnancy and home visits to promote and provide essential newborn care, identify illness, and refer infants, if needed [3]. ASHA workers were trained in these specific competencies of maternal and newborn healthcare using modules 6 and 7 of National Rural Health Mission (NRHM) [4].

A cross-sectional study was conducted to assess the knowledge level and skills of trained ASHA workers in providing HBNC.

A cross-sectional study was conducted in Anand and Umreth talukas (sub-districts) of Anand district of Gujarat, India between May and July 2015, after acquiring permission from state healthcare authorities. The Institutional Ethics Committee approved the study. Sample size required was calculated based on results of previous studies. State healthcare authorities provided the names of ASHA workers to be included in the survey.

A structured questionnaire consisting of 34 questions was developed by the authors using ASHA training modules 6 and 7 of NRHM. It was translated into the local language, Gujarati, and back-translated to ascertain quality of translation. The questionnaire was pre-tested on four ASHA workers who were not included in the study and were not part of the list provided.

The ASHA workers were also evaluated on their performance of the following skills: hand-washing, weight-recording, temperature-recording, kangaroo mother care (KMC) positioning, and bag and mask ventilation (BMV). The checklists used for hand- washing, measuring temperature, and weighing the baby were as per training module 6 of NRHM [4]. The checklists for BMV and KMC were prepared according to the Navjat Shishu Suraksha Karayakam (NSSK) manual [5].

Each participant received one point for correctly performing a step and zero points for not performing / incorrectly performing a step. Scores for each skill were calculated. Performance in a particular skill was considered satisfactory if a participant correctly performed 80% of the enlisted steps without missing any critical steps of the skill. The critical steps were determined by circulating the checklists among 10 pediatricians.

Self-reported maternal and neonatal health field performance of ASHA workers over the past one year was collected.

All the study tools used are provided in Web Annexure 1.

Independent sample t-test/Chi-square test were used to determine associations at the univariate level depending on the types of variables involved. The data were analyzed using Statistical Package for the Social Sciences (SPSS version 14).

All 100 ASHA workers who were approached participated in the study. All belonged to the local community. The mean (SD) theory score of the participants was 16.7 (3.16) out of 34. The mean score was similar for both Anand and Umreth talukas [16.9 (3.12) vs 16.5 (3.22), P=0.55]. Satisfactory skills were found in 52%, 61%, 43%, and 68% of ASHA workers for temperature measurement, hand washing, weight measurement, and KMC, respectively. None of the participants demonstrated satisfactory skills in bag and mask ventilation. No significant difference was observed in any skill between the two sub-districts (Table I). The self-reported field performance of ASHA workers is shown in Table II.

	TABLE I  Skill Assessment of ASHA Workers 

TABLE II	Self-reported Field Performance of ASHA Worker in Past One Year

This study demonstrates that the knowledge and skills of ASHA workers regarding newborn care is sub-optimal. Although the institutional delivery rate is satisfactory, it is difficult to ascribe the same to ASHA. Specifically, the postnatal care including identification of sick newborns, counseling for breastfeeding and KMC is sub-optimal and skin-to-skin care is not practiced adequately. Although self-reported, major variability was observed in the workload of ASHA workers.

The limitations of the study include the possibility that simulation-based skill assessment may have led to some improved performance due to Hawthorne effect. The counseling skills of ASHA workers could not be assessed. Authors were unaware how Government of Gujarat selected 100 ASHA to be included for the study. Possibility of selection bias cannot be ruled out and hence the sample may not be representative.

Previous studies also reported sub-optimal knowledge and skills of ASHAs regarding HBNC, though they lacked detailed evaluation of knowledge, and well-structured skills assessment [6-8]. More than 90% of the ASHA correctly answered questions regarding first examination of baby, early initiation of breastfeeding, timely initiation of complementary feeding, feeding of high risk babies, and care of umbilical cord. Similar finding is corroborated by studies from Maharashtra and West Bengal [6,7]. Although the mean score of the ASHA workers in all the skill sets was good, except for bag and mask ventilation, they missed one or more critical steps leading to unsatisfactory result. Similar observation was reported by Stalin, et al. [8] for weight measurement.

The Gadchiroli trial demonstrated the feasibility and effectiveness of female community health worker in providing HBNC almost two decades ago [9]. Health workers from local community may enhance outreach as well as cultural linkage between communities and health delivery systems, but various personal, professional, organizational, and external environmental factors may influence their expected performance [10,11]. Proper training of health workers is the backbone for successful implementation of HBNC. Simpler, smaller modules highlighting the most important points and frequent refresher courses with constant supportive supervision needs to be assessed through implementation research to inform policy. Good logistic support, improved work environment, along with timely and adequate incentives may enhance the performance of ASHAs. Considering the complexity of the health delivery system, a dedicated female health worker for maternal and newborn care can be tried on an experimental basis.

Acknowledgement: Ms Nisha Fahey for language edit of the manuscript.

Contributors: SB: designed the study, collected the data, wrote the paper, and approved the final manuscript; SN: conceived the study, designed the study, gave critical inputs to the paper, and approved the final manuscript; NS: collected data, gave inputs to the paper, and approved the final manuscript; RS: conceived the study, collected data, revised the manuscript for important intellectual content and script and approved the final manuscript; AP: designed the study, analyzed and interpreted the data, wrote the paper and approved the final manuscript; SN: will be the guarantor for the paper.

Funding: None; Competing interest: None stated.