Maternal Anemia Training Module

Conducted by Government of Jharkhand

Supported technically by A2Z Micronutrient Project

Participants
Supervisors LHV, Mukhya Sevikas
ANM, AWW, ASHA, Sahiyas

Prepared by
Professor Prakash V Kotecha
Technical Advisor,
A2Z, the USAID Micronutrient Project
AED India
 Objectives of the Training

Broad Objective

The training for one day will provide basic information to front line workers about
anemia in India and Jharkhand and the program in place for anemia control in
Jharkhand with its importance and the program contents. The important focused
component of the training is then to build the capacity of the front line workers to
effectively deliver the service components including counseling to the clients and
their family members that will facilitate the clients to use the services and
demand for the available services.

Specific Objectives

1. Participants will know what is anemia, its dangers and why it occurs in
pregnant women, how widespread it is in Jharkhand and how to control it
2. Participants will be able to describe current programs for reducing
maternal anemia in Jharkhand
3. Participants will know how to identify ALL PW in their area; how to deliver
a package of anemia interventions to them through AWC and special
arrangements for left-outs; and how to counsel mothers
4. Participants will know how to carry out supporting actions for delivering
services to pregnant women
5. Participants will develop micro plans to reach ALL women through RI/NHD
and other special outreach activities for non-AWC listed women

Material Required for the Training

Handouts, Counseling Cards, Posters, Number of flip charts, pen, pencils,
calculators, Plain papers, Erasers, color cards (VIPP cards)
Prior Information Required
AWW, ANM may be requested to bring with them their centers basic information
that will include population and village/s covered by them, beneficiaries
registered and the copy of the last monthly report sent.
Training Content

Session I: Welcome and Introduction: 25 Minutes:

It is desired that every participant and facilitator put in large bold letter name tag
and attach it to their dress so that every one can interact with each other by
name.

Senior government official present (or as appropriate) welcomes participants and

mentions briefly the objectives of the training highlighting the skill development
aimed in the training and requests participants to actively participate

Coordinator then requests every participant to introduce themselves: they may

give their name, place of working, designation and if they have seen a case of
anemia, one or two symptoms that they noticed. Introduction needs to be short.
If the pre-test questionnaire is prepared, this is the time when it needs to be
introduced and shared for 10 minutes. Participants need not identify them selves.
Encourage them to be honest in answering as this is not THEIR examination but
is a TOOL to guide training content
Session II: What is Anemia 50 minutes

Objective of session II: Participants will know what is anemia, its dangers
and why it occurs in pregnant women, how widespread it is and how to
control it

Facilitator: Medical Person Available or Anemia Coordinator (knows the

time limit and also the contents keeping in mind the front line workers level
of understanding)

What is Anemia and how widespread is it? (10 minutes)

(Share with participants hand outs in local language and in big bold letters with
pictures preferably, enclosed as Annexure 2 main points as below).
Iron deficiency is the most common form of malnutrition in the world, affecting
more than 2 billion people globally. Iron deficiency anemia (inadequate amount of
red blood cells caused by lack of iron) is highly prevalent in less-developed
countries but also remains a problem in developed countries where other forms
of malnutrition have already been virtually eliminated. Iron deficiency is not the
only cause of anemia, but where anemia is prevalent; iron deficiency is usually
the most common cause. The prevalence of anemia is defined by low
hemoglobin. (Less than 12 g/dL is anemic for non pregnant and less than 11 g/dL
for pregnant woman is criteria to diagnose a woman to be anemic)
Recent studies have shown that in India anemia is very common and Jharkhand
is having second highest level of anemia among the entire country.
Iron deficiency generally develops slowly and is not clinically apparent until
anemia is severe even though functional consequences already exist. Where iron
deficiency anemia is prevalent, effective control programs may yield benefits to
human health.

Consequences of Anemia (10 minutes)

1. Increased chance of death during delivery: Overall, about 20 percent of
maternal and perinatal mortality in developing countries can be attributed
to anemia. Recent work has shown that most of this impact is in the mild
 and moderate grades of anemia, rather than being limited to severe
anemia.

2. Low birth weight babies born: Anemia in pregnant women results in lower
birth-weight babies who have a higher risk of death.

3. Cognitive Functions Limitation: Iron deficiency with or without anemia

reduces work productivity in adults and limits cognitive development in
children thus limiting their achievement in school and ultimately reducing
investment benefits in education.

Mild and moderate anemia also are detrimental to health and contributes to
larger proportion of total ill effects due to anemia

How to control Anemia? (10 minutes) (USE the TIN Plate that we have
developed)

1. Register as soon pregnancy is noticed.

2. Take one tablets of IFA tablet every day at night before going to sleep
after dinner from fourth month onwards
3. Need to increase amount of food consumed in pregnancy, one or two
extra meals during pregnancy besides normal food
4. Deworming dose, one course of six tablets (one if albendazole) after four
months of pregnancy.
5. Malaria prevention (bednets) and immediate treatment for fever.
Current Scenario of Anemia Control in Your Area (20 minutes)

This should be converted in to group work after a quick question of concern that
the program has not worked well till now. Why has it not worked well?
Group task should be:
Review the current anemia control program? Why it is not working well?
[Does it have supply problem? Do women get IFA and not consume? They
consume and still anemia continues? Do they get extra food from ICDS? Do they
eat extra food at home? Are worm infections very common? Are you convinced
that IFA is good and should be consumed? If yes why, if no why]
Session III: Current program Situation 20 minutes

Objective of Session III: Participants will be able to describe current

programs for reducing maternal anemia

Facilitator: This is interactive and participatory sessions and monotony and

lecturing should be avoided here.

Ask participants to say what they are doing at present for pregnant mothers for

1. IFA,
2. Deworming,
3. Extra food for pregnant mothers, (ICDS and otherwise)
4. Malaria

Ensure participations and encourage talking by everyone turn by turn without

repetition of activities. Encourage them to say everything that they do at the
clinic, during field visit and at RI sessions. Find out what messages are being
given along with above services and note down. Do not at this stage criticize.

Mukhya mantri Janani Shishu Swasthya Abiyan & JSY: Briefly review and
discuss Mukhya mantri Janani Shishu Swasthya Abiyan and how this new
activity relates and strengthens anemia reduction program for pregnant women.
Session IV: How to deliver the comprehensive package 3 hours

Objectives: participants will know how identify ALL PW in their area; how to
deliver a package of anemia interventions to them through AWC and special
arrangements for left-outs; and how to counsel mothers
Part I: How to identify all pregnant mothers?

Step I: Identify Gap

This part of the training is a self learning exercise. Participants are asked to refer
to their records and register the population served and number of pregnant
mothers registered for the service. We then request them to apply birthrate
(when not available; the thumb rule of 3% of birthrate and about 10% of
pregnancy wastage so 3.3% will be pregnancy rate). This is the number of total
pregnant women in one year who would deliver. At any given point of time
referring to only second and third trimester, about half of total women likely to be
pregnant in one year, will be in second and third trimester and they need to be
registered with them at any given point of time.
Area covers 1000 population: Expected birth is 30. Expected pregnancy 33
Expected number of pregnant women in second and third trimester in any one
month will be 33/2 equivalent to 16-17 pregnant women who should be
registered. Any number shorter than this is a gap suggesting they have not been
able to reach.
Total population served= 1000 X
Total pregnancy expected= 33 X
Total pregnancy in any month in second and third trimester= 17 X(approximately)
Total registered pregnant women=Y
Gap =17 X – Y (if 17X>Y)

Concept needs to be simplified for the understanding.

Step II: How to reach out to those women who are not registered?
Having identified the missing women, find out why are they not registering?
Specific community, specific area, caste/religion groups? How best to reach out
to them and motivate and convenience them to come forward? Alternatively how
to reach out to them for minimum package of services? What will be the role of
ASHA/Sahiya? Who else can help to reach out and provide services and
counseling? Transfer these names to ANM for possible depot holder in out reach
area that can provide IFA, deworming medicine to these left out groups.
Step III: How to counsel the mothers?
Counseling does not mean sharing information. It means to be able to
understand the need of the client and provide and assist her with what she really
needs. Helping her in taking decision for action. Basic steps of counseling
include
• Greet: Mothers should be greeted and felt welcomed and made comfortable.
• Ask: Make sure you ask relevant questions in simple, short sentences that mother
understands and feels comfortable in answering
• Listen: It is very important to carefully listen what she has to say, and her
concerns. It is necessary when advice is given; it is given based on her needs and
is not generic. To do this it is important to listen to what mother has to say.
• Praise: To make her follow what advice is given, it is important she has trust in
you and in the system. This is best obtained by genuine praise for points which
are praise worthy. The fact that she is in the counseling session is bear minimum
positive point for praise. If she comes for counseling or for ANC regularly, you
can appreciate that or her diet or her weight gain
• Advise: Package for anemia control to mothers needs to be advised but keeping in
mind, what she is following already. What she follows need to be appreciated and
what she needs to be following now onwards need to be explained with reasons
• Check understanding: This is important step for effective communication. We
have advised mothers for steps and counseled but has she understood correctly?
This needs to be checked by asking appropriate questions. E.g. How many iron
tablets you will take? What part of the day will you take iron tablets? Questions
should not be asked in leading format where answer can emerge as “yes” or
“no” as we will not be able to ensure the understanding when she says “yes”,
whether she has really understood what is being conveyed.
SERVICE PACKAGE FOR ANEMIA CONTROL:

1. Advise for one or two extra meal during pregnancy: Woman will in
normal case increase weight of about 8-12 kg during pregnancy; this goes
towards weight increase due to growing foetus; increased size of uterus,
placenta and increased amount of blood volume plus preparation for breast
feeding. Not all weight is for growing foetus; but it is important to gain minimum of
8 kg weight during pregnancy and for that extra food is required.

2. IFA Supplementation: One IFA tablet daily to be taken from 4th month of
pregnancy. It is preferable to take this tablet after food and preferably (not
necessarily) at night. This advice is to avoid likely side effects. Following
components need to be stressed:

1. How many IFA tablets to take? One a day after 4 months or pregnancy:
minimum 100 tablets.
2. When to be taken? It should be taken after food to avoid side effects and
to avoid those sensation it is better taken at night; so the woman goes to
sleep after that and would not have side effects perceived
3. Why it should be taken? We need to explain the mother that it is good
for her health and for her child’s physical and mental health. Child is likely
to be clever and would have better capacity to fight against diseases if
mother takes ALL IFA tablets during pregnancy.
4. Side Effects: Possible side effects like nausea and black color stool should
be explained to the mother with assurance that these are not serious side
effects and nausea would decline on continuation of taking tablets. Black
color stool will continue but is harmless. Any persistent side effect for long
time, doctor should be consulted.
5. The tablets should be kept away from the children to avoid accidental
consumption of tablets by the children
 6. Advice to use IFA regularly also needs to be shared with the family
members who could then support the regular IFA consumption.
Particularly with husband and mother in law.
3. Deworming medicine one dose after 3 month of pregnancy:
Advise all pregnant mothers, for one course of deworming medicine, after three
months of pregnancy, any time. The one full course of deworming medicine dose
consisting of 6 tablets of mebandazole (one tablet to be taken twice a day for
three days) needs to be provided. If albendazole is available a single dose of
albendazole needs to be given instead of six tablets of mebandazole.
4. Protection form Malaria
Mothers if develop fever, it is possible that fever is due to malaria. So she should
get herself examined for blood smear and if she has malaria, treatment should be
taken for the same. Even ASHA/Sahiya kits have medicines. To avoid getting
malaria, she should sleep under mosquito net preferably insecticide impregnated
mosquito nets.
5. Food from ICDS
If the woman is eligible to get ICDS take home ration (THR), she should regularly
get it and consume it herself without sharing it with any other members.
Step IV: Practice for Counseling:
This is important step for capacity building. Every participant will get an
opportunity to do a supervised counseling to the mother. Supervisor would
observe the counseling without any interruption and encourage the participant to
complete counseling based on the learning. After the counseling is over,
supervisor would give feed back to the participants from counseling skills point of
view as well as contents point of view. These would include principles of
counseling observed as discussed above and the package of services discussed
as above. In doing so, supervisor would also follow counseling skills steps and
encourage the participants first of the correct actions and then constructively put
forward the observations that needed to improve.
This is the important step for capacity building and should not be rushed.
Adequate provision for timings and providing opportunity for the counseling be
important and integral part of the training.
Step V: Self Assessment Form: (Enclosed)
To further strengthen the capacity building, based on what the participants are
expected to do after they return to their service units, a self assessment form is
devised. It is important that participants understand the purpose of this form and
how to use this form. By rotation each of the participants can read question by
question this form, discuss whether questions raised here are relevant and would
help them to monitor them selves or not, taking their feed back in the process,
final self monitoring format can be evolved. This self monitoring format they
would then carry with them. Medical Officer in charge be then motivated to
supply these forms to each participants in the subsequent block meeting and
discuss the completed forms that participants will be encouraged to bring in the
block level meeting. In the block level meeting, this works as monitoring the
activities and also for identifying areas that call for special efforts to improve and
other problem solving approaches.

Session V: Monitoring and support to weak performing area

Objective: Participants will know how to carry out supporting actions for
delivering services to pregnant women. From the reports available, they
will be able to assess their own performance. Over 70% coverage will be
assessed as good, 50-70% will be assessed as average and below 50%
coverage may be considered poor. This will be based on the ANC coverage
(any ANC)

Supply: Participants ANM (form 6) and AWW (MPR) is aware of their format.
These formats give their covered area’s actual population size. Using that
population and applying the area specific birth rate, it is possible to calculate
expected number of women who should have been registered. Applying
principles as in earlier sessions, they will be able to derive their performance
level. This level then can be discussed with Medical Officers and Facilitators and
possible reasons for their good, average and poor performance may be
discussed. From the learning of peers and guidance of the resource person,
strategy to improve for poor and average performance may be planned out.
Similar exercise can be done for IFA supply position and also for IFA distribution.
IFA supply: Target is to have at least minimum two months quota with the sub
health center and this has been possible to calculate based on the total
requirements. A formula for total requirement is based on pregnancy rate at
3.3%. So total number of IFA required for sub health center will be 3.3*total
population. Two month quota for sub health center will be 3.3/6 *total population
served. When IFA stock fall below this number, they MUST request for additional
supply and also follow up for their requirement in next block level meetings and
request MOIC who in turn should procure it from district authorities if he does not
have supply available with him. Similarly at MO PHC level at least one month
supply should be available as buffer supply when any sub health center requests.

Tools and Job Aids:

Counseling Material: For counseling simple tools in form of flip chart and poster
or tin plate are made available or will be made available soon. It is necessary to
have these tools with health workers. The training involves educating and
orienting participants how to use these tools. At what stage of counseling these
charts and poster need to be referred to and how best to use them. Pictures are
area specific and culture specific and messages are short and simple in the
language that community understands and in the local language to facilitate the
community members to grasp the message easily and with interest.

Self Assessment Form: It is proposed that a simple self assessment form

based on the job description of AWW/ANM be shared with participants. This form
is primarily to remind all health care providers as the check list for what task they
are to accomplish to achieve effective intervention for anemia control and
nutrition during pregnancy. If motivated to use properly and the training will cover
this part, this tool will work effectively to discuss areas and level of performance
by health care provider at the cluster/sector meetings and block level meeting.
Collected and compiled properly, this format will also work as monitoring
activities for the job functions of health workers.

Session VI:

Objective: participants will develop micro plans to reach ALL women

through RI/NHD and other special outreach activities for non-AWC listed
women:
Now that what is the intervention required for effectively control anemia is shared
and participants are empowered with the contents for anemia control package
and methodology of how to approach and counsel the clients, this session will be
devoted to make micro plans and details of action and time line to be able to
Medical Officers and CDPO should be resource persons and should be present
when the work plans are shared by the participants in plenary sessions and
assure the participants support as required.
Post training questionnaire can be shared here if planned and available

Training session ends by MOIC / Health / ICDS senior staff thanking

participants for work plans and assuring the support for the task.