Lady Health Workers Guide

© 2007 MKFC Stockholm College

Lady Health Workers Guide

LadyHealth Workers Guide

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contents

our Pakistan – our community takes actioncurrent situation

Health Care System in Pakistan

Lady Health Workers

Improving family and community practices

National Program for Family Planning and Primary Health Care

Childhood mortality is high in Pakistan

Hiv/Aids

Women’s Health

Our Goals

maternal care and children’s healththe major Problems causing neonatal death

mother and child health services needed

Guidelines for postnatal care (WHO 1998)

Our Community makes the difference

better nutrition – for health and develoPment

Challenges

Why breastfeeding

Breastfeeding benefits

good Practice With breastfeeding

Signs that the baby is in a good position for breastfeeding

Signs that the baby is feeding well

Almost every mother can produce enough milk

Substitutes with clean water

the umbilical cord – hoW to Protect

cutting the cord sterile

tie tightly before

Length of the cord stump: 2–3 cm

How to tie the cord

cord care – traditional Practices

Unclean substances dangerous

Traditional cord practices causes infections and death

signs of infection in cord

Clean hands are important!

neonatal deaths

How to avoid – what should we know

20 days cord care is needed

vaccination / immunizationimmunization

Why, When, Where

Immunization is urgent

Age Immunizations to be given

sterile needles

secure the child’s life: vaccinate

Immunization protects against several dangerous diseases

Measles cause deaths

Polio disables

Breastmilk protects too

Vitamin A – No blindness

hygienehygiene Practice

Co-operation upon good.

clean Water

Families and communities

can protect their water supply

Families can keep water clean in the home

Washing hands

diarrhoeaWhy diarrhoea is dangerous

Recommended drinks for a child with diarrhoea

no blindness – Wash the face

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current situationPakistan is a rapidly developing country. Recccently, big economic reforms have resulted in a stronger economic outlook and given growth especially in the manufacturing and financial services sectors.

Health Care System in PakistanHealth care in Pakistan is provided by both public and private systems.

Lady Health WorkersAn example of a promising recent initiative is the lady health worker (LHW) communitycbased program, which is bringing health information to the communities. Presently, 3,000 women are serving as LHWs in their home villages.

The lady workers shall get training in checking weight for age, management of the diarrhoea, counseling on breast feeding and nutrition.

Improving family and community practicesFamilies have major responsibilities for caring their children. Improving family and commuccnity practices is very important in the health work: to reinforce practices that are important for child survival.

National Program for Family Planning and Primary Health CareThe Implementation of the National Proccgramme for Family Planning and Primary Health Care with a communitycbased approach is sound.

Childhood mortality is high in PakistanIn the past progress has been made to reduce childhood mortality and morbidity through

implementation of different primary health care activities.

Major challenges remain and childhood mortalccity and morbidity rates are unacceptably high in Pakistan.

Hiv/AidsHIV is not a dominant epidemic in the adult population of Pakistan. Nevertheless, coupled with an extremely low awareness of HIV/AIDS in Pakistan, as well as a growing number of cases, the AIDS epidemic is poised to take a hold in Pakistan. The government estimates the number of HIV/AIDS cases between 70,000 and 80,000.

Women’s HealthThe Government has signed CEDAW (Convencction on the Elimination of All Forms of Discccrimination Against Women) on 29 February, 1996, and CRC (Child Registration Certificate) and Health and Education issues have become important.

Our GoalsOur Pakistan is committed to the goal of making population in Pakistan healthier, as evidenced by the continuing strong support for the Social Action Program (SAP) in the government’s National Health Policy Guidecclines up to 2010.

Our GoalsOur Pakistan is committed to the goal of making population in Pakistan healthier, as evidenced by the continuing strong support for the Social Action Program (SAP) in the government’s National Health Policy Guidecclines up to 2010.

our Pakistan – our community takes action

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The postnatal period (especially the first 24 hours) is the most critical time: twocthirds of newborn deaths and also of all maternal deaths occur in this period. Maternal health problems are also widespread, complicated in part by freccquent births. The fertility remains high, at 5.3 births per woman, and population growth rates are much higher than elsewhere in South Asia.

• Of every 38 women who give birth, one dies. • The infant mortality rate is 101 per 1,000 and• The mortality rate for children under age

five is 140 per 1,000 births. Acute respiratory infections and diarrhoeal diseases are the leading causes of mortality.

• Annually 500,000 children die from pneumoccnia or diarrhoeal diseases.

the major Problems causing neonatal deathOther than diseases, malnutrition causes many deaths. Malnutrition is not not eating enough. You can be malnourished if you eat the wrong foods – for example too much sugar or not enough vitamins.

In 1987 Ministry of Health in Pakistan reported 51.5% children under 5 years were chronically malnourished.

mother and child health services needed:For Mothers: • Family planning and emphasis on small famcc

ily norm.• Antenatal care.• Postnatal care.• Safe mother hood.• Promotion of breast feeding.

maternal care and children’s health

• Sexually Transmitted Diseases (STD prevention)

For Children:• Immunisation/vaccination.• Primary health care.• Nutrition programme.• Providing free milk, monthly check up of

weight, general conditions of children.

Guidelines for postnatal care (WHO 1998)For the baby• immediate and exclusive breastfeeding• warming of the infant• hygienic care of the umbilical cord• identification of danger signs

For the mother• monitoring and referral for complications

such as excessive bleeding, pain, and infeccction

• counseling on breastfeeding• advice on nutrition, newborn care practices

and family planning• Maternal and newborn postnatal care during

the the first few days after delivery to imccprove survival of both.

• A contact with health services• Healthy household practices

Our Community makes the differenceThe underlying problems that affect health are poverty, illiteracy, women’s low status, inadequate water supplies and sanitation persist.

The goal in our community is to take accction for better lives for all of us.

Our Community makes the differenceThe underlying problems that affect health are poverty, illiteracy, women’s low status, inadequate water supplies and sanitation persist.

The goal in our community is to take accction for better lives for all of us.

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Better nutrition is a prime entry point to endccing poverty and a milestone to achieving better quality of life. Better nutrition means:

• stronger immune systems, • less illness and • better health. Healthy children learn better. Healthy people are stronger, are more able to create opportuniccties to break the cycles of poverty and hunger.

Challenges• Poor nutrition contributes to 1 out of 2

deaths • 1 out of 4 preschool children suffers from

undercnutrition, which can severely affect a child’s mental and physical developccment

• Undercnutrition among pregnant women leads to 1 out of 6 infants born with low birth weight.

• Inappropriate feeding of infants and young children are responsible for onecthird of the cases of malnutrition.

Why breastfeedingBabies who are breastfed have fewer illnesses and are better nourished than those who are fed other drinks and foods.

Almost every mother can breastfeed successccfully. Those who might lack the confidence to breastfeed need practical support of the baby’s father and their family, friends and relatives.

Breastfeeding benefits1. Breastmilk alone is the only food and drink

an infant needs for the first six months. No other food or drink, not even water, is usuccally needed during this period.

2. There is a risk that a woman infected with HIV can pass the disease on to her infant through breastfeeding. Women who are inccfected or suspect that they may be infected should consult a trained health worker for testing.

3. Newborn babies should be kept close to their mothers and begin breastfeeding within one hour of birth.

4. Frequent breastfeeding causes more milk to be produced. Almost every mother can breastfeed successfully.

5. Breastfeeding helps protect babies and young children against dangerous illnesses.

6. A woman employed away from her home can continue to breastfeed her child as ofccten as possible when she is with the infant.

7. Exclusive breastfeeding can give a woman more than 98 per cent protection against pregnancy for six months after giving birth – if her menstrual periods have not reccsumed.

better nutrition – for health and develoPment

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good Practice With breastfeedingA newborn baby needs to remain in skinctocskin contact with the mother as much as possible. It is best for the mother and baby to stay together in the same room or bed.

Having the baby start to breastfeed soon after birth stimulates the production of the mother’s breastmilk.

Many new mothers need encouragement and help to begin breastfeeding. Another woman who has successfully breastfed or a family member, friend or member of a women’s breastfeeding support group can help a mother overcome uncertainties and prevent difficulccties.

How the mother holds her baby and how the baby takes the breast in the mouth are very important.

Breastmilk is the baby’s ‘first immunization’. It helps to protect against diarrhoea, ear and chest infections and other health problems. The protection is greatest when breastmilk alone is given for the first six months and breastfeeding continues well into the second year and beyond. No other drinks or foods can provide this protection.

Substitutes with clean waterUsing breastmilk substitutes, such as infant formula or animal’s milk, can be a threat to infants’ health. This is particularly the case if parents cannot afford sufficient substicctutes, which are quite expensive, or do not always have clean water with which to mix them.

Substitutes with clean waterUsing breastmilk substitutes, such as infant formula or animal’s milk, can be a threat to infants’ health. This is particularly the case if parents cannot afford sufficient substicctutes, which are quite expensive, or do not always have clean water with which to mix them.

Signs that the baby is in a good position for breastfeeding are:

• the baby’s whole body is turned towards the mother

• the baby is close to the mother• the baby is relaxed and happy.

Signs that the baby is feeding well:• the baby’s mouth is wide open• the baby’s chin is touching the mother’s

breast• more of the dark skin around the mothcc

er’s nipple can be seen above the baby’s mouth than below it

• the baby takes long, deep sucks• the mother does not feel any pain in the

nipple.

Almost every mother can produce enough milk when:

• she breastfeeds exclusively• the baby is in a good position and has the

breast well in the mouth• the baby feeds as often and for as long

as he or she wants, including during the night.

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The umbilical cord is a unique tissue in a huccman body. It consists of two arteries and one vein. During pregnancy, the placenta supplies all material for fetal growth and removes waste products. Blood flowing through the cord brings nutrients and oxygen to the fetus and carries away carbon dioxide and metabolic wastes.

When the cord stops pulsating, the umbilical vessels are constricted but are not yet obliterccated. Therefore the cord has to be tied/clamped tightly in order to keep the umbilical vessels occccluded and prevent bleeding.

cutting the cord sterileTo separate the newborn from the placenta, the cord must be cut. The instrument used cuts through living tissue and vessels that are still

connected to the infant’s blood stream (Figure 1); it therefore needs to be sterile to avoid infeccction.

tie tightly beforeA sterile and sharp instrument, such as a new razor blade or scissors, is usually recommended for cutting the cord. Experience with a blunter instrument resulted in more vessel spasm and thus less blood loss. Using a blunt instrument could possibly result in an increased incidence of infection due to more trauma to the tissues. The cord must always be clamped or tied tightccly before cutting.

Length of the cord stump: 2–3 cmThe recommended length of the stump after cutting is usually 2 or 3 cm. The importance of keeping the cord clean and dry and of not letting it come in contact with urine and faeces should be explained to the family.

How to tie the cordThe cord must be always be tied or clamped at the baby’s side before the cutting, since leaving it untied can cause excessive bleeding.

cord care – traditional PracticesA wide variety of traditional practices and beliefs are associated with care of the umbilical cord. These traditional beliefs must be taken into account when introducing clean cord care programmes in a community since these beccliefs may conflict with programme recommenccdations.

Unclean substances dangerousSome traditional practices such as applying unclean substances to the cord are dangerous

the umbilical cord – hoW to Protect

Figure 1: A transection of the abdominal wall: a cord

stump with one vein (a) and two arteries (b) entering the

abdominal wall

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and should be discouraged or replaced with safer alternatives. Practices will not change unccless people are convinced that the new practice is indeed better. Some traditional practices are beneficial and should be promoted, while othccers may be ignored.

Traditional cord practices causes infections and death • In some areas, no tie is used or the cord is

tied only if bleeding occurs. This practice incccreases the risk of bleeding from the stump.

• A variety of tools are used to cut the cord. They are usually items that are available in the house, or that relate to the father’s trade, such as scissors, knives, broken glass or stones. These are rarely cleaned or boiled beccfore use and are dangerous sources of infeccction.

In most cultures, some kind of substance is apccplied to the cord stump. Ash, oil, butter, spice pastes, herbs and mud are substances that are commonly used. These substances are often contaminated with bacteria and spores and thus increase the risk of infection. One of the most dangerous practices is the application of cow, chicken or rat dung to the stump; this is associated with a high risk of neonatal tetanus.

In many cultures it is common to bind the newccborn’s abdomen with cloth or bandages. This practice keeps the stump moist, thus delaying healing and increasing the risk of infection, especially if the material used is unclean.

signs of infection in cordWhen the newborn has systemic signs of infeccction such as fever, lethargy or poor feeding, it

must be treated as for severe bacterial infeccction and antibiotics should preferably be given intravenously. The diagnosis of cord infection is uncertain: the cord may appear unusually moist or smelly, with or without discharge, but there are no other signs. Sometimes there are no obvious outward signs of infection.

neonatal deathsMany infections that leads to death are due to cord infections.

20 days cord care is neededThe cord normally falls off between 5 and 15 days after birth. After the cord separates, the umbilicus continues to elaborate small amounts of mucoid material until complete healing takes place, usually a few days after separation. During this time the umbilicus is still susceptible to infections, although less so than in the first 2–3 days. Infection may delay healing, causing the umbilicus to stay moist for longer periods.

Clean hands are important!The newborn baby has no protective flora at birth. Normal skin flora begin to be acquired within 24 hours. The umbilicus is colonized by bacteria from environmental sources such as the mother and the hands of caregivers.

Clean hands are important!The newborn baby has no protective flora at birth. Normal skin flora begin to be acquired within 24 hours. The umbilicus is colonized by bacteria from environmental sources such as the mother and the hands of caregivers.

How to avoid – what should we know• Current medical practices regarding

when and how to cut the cord, • the length of the remaining stump, • the choice of cord ties and the applicacc

tion of antimicrobials on the stump are identified.

How to avoid – what should we know• Current medical practices regarding

when and how to cut the cord, • the length of the remaining stump, • the choice of cord ties and the applicacc

tion of antimicrobials on the stump are identified.

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Children who are immunized are protected from these dangerous diseases. All children have the right to this protection.

immunizationEvery girl and boy needs to be immunized. And pregnant women need to be immunized to procctect themselves and their infants.

Why, When, WhereIt is essential that all parents know why, when, where and how many times the child should be immunized. Parents also need to know that it is safe to immunize the child even if the child has an illness or a disability or is suffering from malnutrition.

• Immunization protects against several danccgerous diseases. A child who is not immuccnized is more likely to suffer illness, become permanently disabled or become undernourccished and die.

• All children, including those who are disaccbled, need to be vaccinated. The vaccines work by building up the child’s defences against disease. Immunization only works if given before the disease strikes.

Immunization is urgent! Every child needs a series of immunizations during the first year of life. It is essential that infants complete the full number of immunizations – otherwise the vaccines may not work.

Immunization is urgent! Every child needs a series of immunizations during the first year of life. It is essential that infants complete the full number of immunizations – otherwise the vaccines may not work.

• It is safe to immunize a child who has a minor illness, a disability or who is malnourccished.

• All pregnant women need to be protected against tetanus. Even if the woman was imccmunized earlier, she may need additional tetanus toxoid vaccinations.

• Disease can spread quickly when people are crowded together. All children living in congested conditions, particularly in refugee or disaster situations, should be immunized immediately, especially against measles.


At birth BCG**, polio and, in some countries, hepaticctis B

6 weeks DPT**, polio and, in some countries, hepaticctis B and Hib

10 weeks DPT, polio and, in some countries, hepatitis B and Hib14 weeks DPT, polio and, in some countries, hepatitis B and Hib

9 months Measles (12c15 months in industrialized countries) and, in some countries, yellow fever, mumps and rubella.


At birth BCG**, polio and, in some countries, hepaticctis B

6 weeks DPT**, polio and, in some countries, hepaticctis B and Hib

10 weeks DPT, polio and, in some countries, hepatitis B and Hib14 weeks DPT, polio and, in some countries, hepatitis B and Hib

9 months Measles (12c15 months in industrialized countries) and, in some countries, yellow fever, mumps and rubella.

vaccination / immunization

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sterile needlesA new or sterile needle and syringe must be used for every person being immunized. People should insist on this.

secure the child’s life: vaccinateImmunization protects against several dangerous diseasesA child who is not immunized is more likely to suffer illness, become permanently disabled or become undernourished and die.

Immunization protects children against some of the most dangerous diseases of childhood. All children, including those who are disabled, need to be vaccinated. A child is immunized by vaccines, which are injected or given by mouth. The vaccines work by building up the child’s defences against disease. Immunization only works if given before the disease strikes.

Measles cause deathsAll children need to be immunized against measles, which is a major cause of malnutricction, poor mental development, and hearing and visual impairments. The signs that a child has measles are a fever and rash that have lasted for three days or more, together with a cough, a runny nose or red eyes. Measles can cause death.

*National immunization schedules may difccfer slightly from country to country.**BCG offers partial protection against some forms of tuberculosis and leprosy; DPT procctects against diphtheria, pertussis (whoopccing cough) and tetanus.

Polio disablesAll children, everywhere, need to be immuccnized against polio. The signs of polio are a floppy limb or the inability to move. For every 200 children who are infected, one will be disaccbled for life.

Breastmilk protects tooBreastmilk and colostrum, the thick yellow milk produced during the first few days after birth, provide protection against pneumonia, diarrhoea and other diseases. Protection lasts for as long as the child is breastfed.

Vitamin A – No blindnessVitamin A helps children fight infections and prevents blindness. Vitamin A is found in breastmilk, liver, fish, dairy products, some orange and yellow fruits and vegetables, and some green leafy vegetables. In areas of vitaccmin A deficiency, children aged six months and older should be given vitamin A capsules or liquid when they are immunized or during National Immunization Days. Vitamin A is also an important part of measles treatment.

More than half of all illnesses and deaths among young children are caused by germs that get into their mouths through food or waccter or dirty hands. Many of these germs come from human and animal faeces.

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hygiene PracticeMany illnesses, especially diarrhoea, can be prevented by good hygiene practices: • putting all faeces in a toilet or latrine;• washing hands with soap and water or ash

and water after defecating or handling chilccdren’s faeces, and before feeding children or touching food; and

• ensuring that animal faeces are kept away from the house, paths, wells and children’s play areas.

• All family members, including children, need to wash their hands thoroughly with soap and water or ash and water after contact with faeces, before touching food, and before feeding children.

• Washing the face with soap and water every day helps to prevent eye infections. In some parts of the world, eye infections can lead to trachoma, which can cause blindness.

Co-operation upon good.Everyone in the community needs to work together to build and use toilets and lacctrines, protect water sources, and safely dispose of waste water and garbage. It is important for governments to support communities by providing information on lowccost latrines and toilet facilities that all families can afford. In urban areas, governccment support is needed for lowccost sanitacction and drainage systems, improved drinkccing water supply, and garbage collection.

Co-operation upon good.Everyone in the community needs to work together to build and use toilets and lacctrines, protect water sources, and safely dispose of waste water and garbage. It is important for governments to support communities by providing information on lowccost latrines and toilet facilities that all families can afford. In urban areas, governccment support is needed for lowccost sanitacction and drainage systems, improved drinkccing water supply, and garbage collection.

• Only use water that is from a safe source or is purified. Water containers need to be kept covered to keep the water clean.

clean WaterOnly use water that is from a safe source or is purified. Water containers need to be kept covccered to keep the water clean.

Families and communities can protect their water supply by:• keeping wells covered and installing a handcc

pump• disposing of faeces and waste water (especialcc

ly from latrines and household cleaning) well away from any water source used for cookccing, drinking or washing

• building latrines at least 15 metres away and downhill from a water source

Families can keep water clean in the home by:• storing drinking water in a clean, covered

container• avoid touching clean water with unclean

hands• taking water out of the container with a

clean ladle or cup

Washing hands

All family members, including children, need to wash their hands thoroughly with soap and water or ash and water after concctact with faeces, before touching food, and before feeding children.

All family members, including children, need to wash their hands thoroughly with soap and water or ash and water after concctact with faeces, before touching food, and before feeding children.

hygiene

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Soap and water or ash and water should be placed conveniently near the latrine or toilet.• It is especially important to wash the hands

after defecating and after cleaning the botcctom of a baby or child who has just defecatcced. It is also important to wash hands after handling animals and raw foods.

• Hands should always be washed before preccparing, serving or eating food, and before feeding children. Children should be taught to wash both hands after defecating and beccfore eating to help protect themfrom illness.

Children are easily infected with worms, which deplete the body’s nutrients. Children should not play near the latrine or toilet. Shoes should be worn near latrines to prevent worms from entering the body through the skin of the feet.

Children often put their hands into their mouths, so it is important to wash a child’s hands often, especially after they have been playing in dirt or with animals.

Children often put their hands into their mouths, so it is important to wash a child’s hands often, especially after they have been playing in dirt or with animals.

Children living in areas where worms are common should be treated two to three times per year with a recommended anticchelmenthic medication.

Children living in areas where worms are common should be treated two to three times per year with a recommended anticchelmenthic medication.

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Diarrhoea is caused by germs that are swalcclowed, especially germs from faeces.

• Diarrhoea kills children by draining liquid from the body, thus dehydrating the child. As soon as diarrhoea starts, it is essential that the child be given extra fluids as well as regucclar foods and fluids.

• A child’s life is in danger if there are several wacctery stools within an hour or if there is blood in the faeces. Immediate help from a trained health worker is needed.

• Breastfeeding can reduce the severity and frequency of diarrhoea.

• A child with diarrhoea needs to continue eating regularly. While recovering from diarccrhoea, the child needs at least an extra meal every day for at least two weeks

• If the child is dehydrated with severe or perccsistent diarrhoea, only oral rehydration solucction or medicines recommended by a trained health worker should be used.

Why diarrhoea is dangerousDiarrhoea kills children by draining liquid from the body, thus dehydrating the child. As soon as diarrhoea starts, it is essential that the child be given extra fluids as well as regular foods and fluids.

A child has diarrhoea when he or she passes three or more watery stools a day. The more numerous the watery stools, the more dangerccous the diarrhoea.

diarrhoea

Some people think that drinking liquids makes diarrhoea worse. This is not true.

Drinks should be given from a clean cup. A feeding bottle should never be used.

Diarrhoea usually stops after three or four days. If it lasts longer, caregivers should seek help from a trained health worker.

Recommended drinks for a child with diarrhoea:

• breastmilk more often than usual• soups• rice water• fresh fruit juices• weak tea with a little sugar• clean water from a safe source. If there

is a possibility the water is not clean, it should be purified by boiling or filtering.

• oral rehydration salts (ORS) mixed with the proper amount of clean water.

Recommended drinks for a child with diarrhoea:

• breastmilk more often than usual• soups• rice water• fresh fruit juices• weak tea with a little sugar• clean water from a safe source. If there

is a possibility the water is not clean, it should be purified by boiling or filtering.

• oral rehydration salts (ORS) mixed with the proper amount of clean water.

The child should be given extra liquids uncctil the diarrhoea has stopped.After 1 week revisit to health worker revisit.

The child should be given extra liquids uncctil the diarrhoea has stopped.After 1 week revisit to health worker revisit.

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A dirty face attracts flies, spreading the germs they carry from person to person. The eyes may become sore or infected and vision may be imccpaired or lost if the eyes are not kept clean and healthy.

Washing the face with soap and water every day helps to prevent eye infections. In some parts of the world, eye infections can lead to trachoma, which can cause blindness.

Washing the face with soap and water every day helps to prevent eye infections. In some parts of the world, eye infections can lead to trachoma, which can cause blindness.

no blindness – Wash the face