ANM / Multi-Purpose Health Assistant (Female) · Chapter 8

Community Health Nursing and Domiciliary Midwifery

What to remember

Community health nursing looks after the health of the whole community, not just one patient. The ANM is the first contact between the people and the health system.
The health system has three levels in rural areas: sub-centre, primary health centre (PHC) and community health centre (CHC). Each serves a fixed population.
Domiciliary midwifery means care of mother and baby at home. Planning, clean delivery, danger-sign recognition and early referral are the key skills.

Concepts and levels of prevention

Health (WHO) is a state of complete physical, mental and social well-being, and not merely the absence of disease.
Community health nursing combines nursing, public health and social care to promote health, prevent disease and give care to families and groups.
Primary prevention: health promotion and specific protection, such as immunisation, nutrition and sanitation.
Secondary prevention: early diagnosis and prompt treatment, such as screening and treating anaemia.
Tertiary prevention: limiting disability and rehabilitation.
Primary health care was declared the key strategy at the Alma-Ata conference in 1978: "Health for All". Its principles are equitable distribution, community participation, intersectoral coordination and appropriate technology.

Rural health infrastructure

Unit	Population norm (plains)	Population norm (hilly or tribal)	Main staff
Sub-centre	5,000	3,000	ANM (female health worker), a male health worker
Primary health centre	30,000	20,000	Medical officer, staff nurse, pharmacist, lab technician
Community health centre	1,20,000	80,000	Specialists (surgeon, physician, obstetrician, paediatrician)

The CHC is also the first referral unit (FRU) when it provides emergency obstetric care and blood storage.
A sub-centre is the most peripheral contact point between the primary health care system and the community.
ASHA (Accredited Social Health Activist) is a village-level woman volunteer who links people with services, motivates for institutional delivery and immunisation, and escorts patients. Anganwadi worker provides nutrition and pre-school education under the ICDS scheme.
Village Health and Nutrition Day (VHND): a monthly outreach session at the village or anganwadi for immunisation, antenatal check-ups, nutrition and counselling.
Village Health, Sanitation and Nutrition Committee involves the village in planning health work.
In Andhra Pradesh, the village and ward secretariat system places an ANM or ward health secretary at the village or ward level to deliver health services and keep records. The state also runs the 104 and 108 services for mobile health services and emergency ambulances.

Role and duties of the ANM

Registration and follow-up of pregnant women and infants (the eligible couple register, antenatal register).
Conduct deliveries at sub-centre and assist at home when needed, and refer complications.
Immunisation sessions, vitamin A and iron-folic acid distribution.
Family planning counselling and services.
Treat minor ailments, give first aid, and manage diarrhoea with ORS and zinc.
Health education, school health visits and support to national disease control programmes (malaria, tuberculosis, leprosy, HIV).
Maintain records, prepare monthly reports and send them to the PHC. Keep a family folder.
Guide and support ASHAs, and work together with anganwadi workers (who are supervised under ICDS).

Home visits and the bag technique

Home visit: a planned visit to the family to assess, teach and help. First visit is for establishing rapport and gathering facts. Choose a time that suits the family.
Purposes: early detection of disease, health education, follow-up of antenatal, postnatal and newborn cases, and finding eligible couples for family planning.
Bag technique: the nurse carries a bag with essential supplies to the home. Steps include: place the bag on a clean surface, wash hands before and after, use items with minimum contamination, and repack in a way that keeps clean and used items separate.
Contents of the ANM kit: thermometer, stethoscope, blood pressure apparatus, weighing scale, measuring tape, hand-washing items, gloves, urine testing kit, haemoglobin testing kit and basic medicines.

Principles of domiciliary midwifery

Antenatal preparation for home delivery: choose a clean, well-lit, ventilated room with a hard bed and ready water supply; arrange a trained birth attendant; keep emergency transport and a birth plan ready.
Birth preparedness: identify the facility for referral, keep money and transport ready, and a blood donor if possible.
Clean delivery kit includes a plastic sheet, soap, sterile blade, clean cord ties, clean cloth to wrap the baby, gloves and a sterile gauze.
Six cleans: clean hands, clean delivery surface, clean perineum, clean blade for cutting the cord, clean cord tie, and clean cloth for the baby.
Home delivery by a skilled person is a fallback. A facility delivery is the strongly encouraged choice because it can manage complications.
Refer a woman for facility delivery if she has: previous caesarean, bleeding, twins, abnormal lie of the baby, high blood pressure, severe anaemia, a premature or very small baby, prolonged labour, or very short stature.
After home delivery: visit within 24 hours, then on day 3, day 7 and as needed. Home-based newborn care visits are made by the ASHA.

Immunisation (Universal Immunisation Programme)

Age	Vaccines
At birth	BCG, OPV zero dose, Hepatitis B birth dose
6, 10 and 14 weeks	OPV, Pentavalent (DPT + Hepatitis B + Hib), rotavirus; fractional IPV at 6 and 14 weeks; PCV at 6 and 14 weeks (booster at 9 months)
9 to 12 months	Measles-Rubella (MR) first dose, vitamin A first dose
16 to 24 months	DPT booster, OPV booster, MR second dose
5 to 6 years	DPT booster
10 and 16 years	Td
Pregnant women	Td (two doses, or one booster)

Cold chain: keep vaccines at +2 °C to +8 °C from the factory to the child. Equipment: ice-lined refrigerator (ILR), deep freezer, cold box, vaccine carrier and ice packs.
Freeze-sensitive vaccines: DPT, pentavalent, Td, Hepatitis B and others. They are damaged by freezing. BCG, measles and OPV can be frozen, but BCG and measles are damaged by light and heat.
Vaccine vial monitor (VVM): a heat-sensitive label that shows if the vaccine has had too much heat. Discard if the inner square matches or is darker than the outer circle.
Shake test checks whether freeze-sensitive vaccines have been frozen.
Open vial policy: some vaccines can be used on later days if kept properly. BCG, measles and MR must be discarded 4 hours after reconstitution.
Never mix different vaccines in the same syringe. Use a new auto-disable syringe for each child.
Observe the child for 30 minutes after injection for adverse events following immunisation.

Vital events, records and basic epidemiology

Registration of births and deaths is mandatory under the Registration of Births and Deaths Act (1969). Birth and death are reported within 21 days.
Vital statistics: birth rate = live births per 1,000 mid-year population. Infant mortality rate = infant deaths (under 1 year) per 1,000 live births. Neonatal mortality rate = deaths in first 28 days per 1,000 live births. Maternal mortality ratio is per 100,000 live births.
Epidemiology triad: agent, host and environment.
Incubation period: time between entry of the organism and first symptoms. Isolation: separating the sick. Quarantine: limiting movement of healthy contacts for the incubation period.
Surveillance is the continuous collection, analysis and use of health data.
Levels of record: Eligible couple register, antenatal register, immunisation register, birth and death register.

Environmental sanitation

Safe water: chlorination with bleaching powder or chlorine tablets, boiling, and filtration. Protect wells from contamination.
Safe disposal of excreta using sanitary latrines. Safe disposal of waste using segregation.
Control of flies, mosquitoes and rats: remove breeding sites.
Biomedical waste at the sub-centre is segregated by colour-coded bags (yellow for soiled and anatomical waste, red for contaminated plastics, white for sharps, blue for glassware).

Exam traps

Sub-centre serves 5,000 in plains and 3,000 in hills (not the other way).
PHC population is 30,000, and CHC is 1,20,000.
The ANM is a member of the sub-centre team, not the PHC doctor team.
ASHA is a volunteer and not a regular salaried staff member.
BCG and measles vaccines are not freeze-sensitive in the same way as DPT and Hepatitis B.
Birth and death registration is within 21 days.
Cold chain temperature is +2 °C to +8 °C, not 0 °C to 4 °C.
Quarantine applies to healthy contacts, and isolation applies to patients.
The Alma-Ata declaration is from 1978 and is about primary health care.
A VHND is monthly, not weekly.

One-liners

1. Sub-centre norm: 5,000 (plains).
2. PHC norm: 30,000 (plains).
3. CHC norm: 1,20,000 (plains).
4. Cold chain range: +2 °C to +8 °C.
5. ASHA stands for Accredited Social Health Activist.
6. Alma-Ata declaration year: 1978.
7. Registration of births and deaths: within 21 days.
8. Infant mortality is per 1,000 live births.
9. Maternal mortality ratio is per 100,000 live births.
10. Pentavalent covers diphtheria, pertussis, tetanus, hepatitis B and Hib.
11. MR first dose at 9 to 12 months.
12. White container is for sharps.

Practice questions

The population norm for a sub-centre in plain areas is:
1. 1,20,000
2. 30,000
3. 3,000
4. 5,000
Answer
D. 5,000
Sub-centre: 5,000 in plains and 3,000 in hilly or tribal areas.
The population norm for a primary health centre in plain areas is:
1. 5,000
2. 80,000
3. 1,20,000
4. 30,000
Answer
D. 30,000
PHC serves 30,000 (20,000 in hills).
The population norm for a community health centre in plain areas is:
1. 50,000
2. 1,20,000
3. 30,000
4. 5,000
Answer
B. 1,20,000
CHC serves 1,20,000 (80,000 in hills).
The most peripheral contact point between the community and the health system is the:
1. district hospital
2. sub-centre
3. community health centre
4. medical college
Answer
B. sub-centre
Sub-centre is the first contact point.
The Alma-Ata declaration on primary health care was made in:
1. 1978
2. 1986
3. 1948
4. 2000
Answer
A. 1978
The Alma-Ata conference of 1978 declared Health for All through primary health care.
ASHA stands for:
1. Authorised School Health Assistant
2. Area Sanitation and Health Agent
3. Assistant Social Health Aide
4. Accredited Social Health Activist
Answer
D. Accredited Social Health Activist
ASHA is a village-level woman health volunteer.
The cold chain temperature range for vaccines is:
1. -10 °C to 0 °C
2. +10 °C to +20 °C
3. 0 °C to +2 °C
4. +2 °C to +8 °C
Answer
D. +2 °C to +8 °C
Vaccines are kept at +2 to +8 °C.
Which vaccine is given at birth in the national schedule?
1. BCG
2. Td
3. Measles-Rubella
4. DPT booster
Answer
A. BCG
BCG, OPV zero dose and hepatitis B birth dose are given at birth.
Pentavalent vaccine does NOT protect against:
1. Haemophilus influenzae type b
2. polio
3. diphtheria
4. hepatitis B
Answer
B. polio
Pentavalent covers DPT, hepatitis B and Hib; polio is given as OPV or IPV.
The first dose of Measles-Rubella vaccine is given at:
1. 6 weeks
2. 5 years
3. 14 weeks
4. 9 to 12 months
Answer
D. 9 to 12 months
First MR dose is at 9 to 12 months.
Births and deaths must be registered within:
1. 2 months
2. 1 year
3. 21 days
4. 7 days
Answer
C. 21 days
Registration of Births and Deaths Act sets 21 days.
Infant mortality rate is expressed per:
1. 1,000 live births
2. 1,000 mid-year population
3. 100,000 live births
4. 10,000 live births
Answer
A. 1,000 live births
IMR = deaths under 1 year per 1,000 live births.
Isolation differs from quarantine because isolation is for:
1. sick persons with a communicable disease
2. healthy contacts only
3. vaccinated persons
4. travellers only
Answer
A. sick persons with a communicable disease
Quarantine limits healthy contacts; isolation separates the sick.
The epidemiological triad consists of:
1. germ, vector and soil
2. agent, host and environment
3. agent, nurse and community
4. host, vaccine and drug
Answer
B. agent, host and environment
Agent, host and environment interact to cause disease.
Which colour-coded container is meant for sharps in biomedical waste segregation?
1. Yellow
2. White
3. Red
4. Green
Answer
B. White
Sharps go in a white translucent puncture-proof container.
Vaccine vial monitor shows that a vaccine should be discarded when:
1. the vial has been shaken
2. the label has faded
3. the inner square is lighter than the circle
4. the inner square is as dark as or darker than the outer circle
Answer
D. the inner square is as dark as or darker than the outer circle
A dark square means heat exposure.
A freeze-sensitive vaccine is:
1. BCG
2. OPV
3. pentavalent
4. measles
Answer
C. pentavalent
DPT-containing vaccines and hepatitis B are damaged by freezing.
BCG and measles vaccines should be discarded after reconstitution within:
1. 24 hours
2. 4 hours
3. 7 days
4. 1 hour only
Answer
B. 4 hours
Open vials of reconstituted BCG and measles are discarded after 4 hours.
The ANM at a Village Health and Nutrition Day (VHND) session typically:
1. gives immunisation and antenatal check-ups
2. teaches mathematics
3. performs major surgery
4. registers land records
Answer
A. gives immunisation and antenatal check-ups
VHND is a monthly outreach for immunisation, ANC, nutrition and counselling.
Which family needs referral for facility delivery rather than home delivery?
1. A woman with Hb of 12 g/dl
2. A woman with normal blood pressure
3. A woman with twin pregnancy
4. A healthy woman with a normal first pregnancy and no risk factors
Answer
C. A woman with twin pregnancy
Twins are a high-risk condition needing facility delivery.
A child is being vaccinated with a new auto-disable syringe for each dose. This is primarily to:
1. save vaccine
2. speed up the session
3. reduce cost
4. prevent infection spread
Answer
D. prevent infection spread
A new sterile syringe for every child prevents cross-infection.
A healthy contact of a measles case is asked to stay away from school for the incubation period. This is:
1. immunisation
2. fumigation
3. isolation
4. quarantine
Answer
D. quarantine
Restricting healthy contacts is quarantine.
Water in a village well is disinfected using:
1. alum only
2. sand
3. bleaching powder or chlorine tablets
4. sunlight only
Answer
C. bleaching powder or chlorine tablets
Chlorination is the standard disinfection method.
A mother brought her baby at 6 weeks of age for vaccination. The vaccines due then include:
1. BCG only
2. Td
3. MR first dose
4. OPV, pentavalent and rotavirus (first doses)
Answer
D. OPV, pentavalent and rotavirus (first doses)
The first doses of OPV, pentavalent, rotavirus and others are due at 6 weeks.
A home visit is best planned:
1. at a time convenient for the family
2. during meal times
3. very late at night
4. only during festivals
Answer
A. at a time convenient for the family
Plan visits to suit the family and the purpose.
A child's DPT vaccine vial was kept in the freezer. The right action is to:
1. use it immediately
2. do a shake test and discard it if it fails
3. give a double dose
4. use only for older children
Answer
B. do a shake test and discard it if it fails
Frozen DPT-containing vaccine may be damaged; check by shake test.
An ANM must walk 2 km to a hamlet on foot with supplies. The bag technique helps her to:
1. carry essentials and prevent contamination during the visit
2. avoid hand washing
3. avoid examining the patient
4. skip record keeping
Answer
A. carry essentials and prevent contamination during the visit
The bag technique keeps clean and used items separate.
Match: Which pairing is correct?
1. PHC: district hospital
2. CHC: specialists and first referral unit
3. ASHA: salaried doctor
4. Sub-centre: medical college
Answer
B. CHC: specialists and first referral unit
CHC offers specialist care and acts as an FRU.
Match: Which pairing of colour and waste is correct?
1. White: soiled dressings
2. Yellow: glass
3. Blue: glassware
4. Red: sharps
Answer
C. Blue: glassware
Blue is for glassware and implants; red for contaminated plastics; white for sharps.
Match: Which pairing of age and vaccine is correct?
1. 16 to 24 months: DPT booster
2. 10 years: MR first dose
3. 9 months: BCG
4. Birth: Td
Answer
A. 16 to 24 months: DPT booster
The DPT booster is at 16 to 24 months.
Which of the following statements is/are correct? 1. A sub-centre serves 5,000 people in plains. 2. A PHC is run by a medical officer.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. The ANM is a member of the PHC doctor team. 2. The ANM is the first contact between people and the health system.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
B. 2 only
ANM works at the sub-centre as a female health worker.
Which of the following statements is/are correct? 1. Primary prevention includes immunisation. 2. Secondary prevention includes early diagnosis and prompt treatment.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. Quarantine is applied to patients. 2. Isolation is applied to healthy contacts.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
D. Neither 1 nor 2
The terms are reversed in both statements.
Which of the following statements is/are correct? 1. Birth rate is expressed per 1,000 mid-year population. 2. Maternal mortality ratio is expressed per 1,000 live births.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
MMR is per 100,000 live births.
Which of the following statements is/are correct? 1. The Registration of Births and Deaths Act was enacted in 1969. 2. Registration is required within 21 days.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are correct.
Which of the following statements is/are correct? 1. Vitamin A first dose is given at 9 months along with the measles vaccine. 2. DPT booster is given at 6 weeks.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
The DPT booster is at 16 to 24 months.
Which of the following statements is/are correct? 1. A clean delivery kit includes a sterile blade and a clean cord tie. 2. Home delivery by a skilled person is preferred over facility delivery.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
A. 1 only
Facility delivery is the preferred choice because it can manage complications.
Which of the following statements is/are correct? 1. The Alma-Ata conference promoted community participation. 2. Primary health care is based on appropriate technology.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both are principles of primary health care.
Which of the following statements is/are correct? 1. VHND is held monthly at the village. 2. Birth preparedness includes keeping transport and money ready.
1. 1 only
2. 2 only
3. Both 1 and 2
4. Neither 1 nor 2
Answer
C. Both 1 and 2
Both statements are correct.
The health system's first referral unit in a rural area is usually the:
1. sub-centre
2. community health centre
3. anganwadi centre
4. village secretariat
Answer
B. community health centre
The CHC works as the FRU with emergency obstetric care.
An ice-lined refrigerator is used to:
1. sterilise instruments
2. store blood
3. keep food for staff
4. store vaccines at the PHC
Answer
D. store vaccines at the PHC
ILR holds vaccines in the cold chain.
The 'Health for All' goal through primary health care was set at:
1. Delhi 1969
2. Alma-Ata
3. Ottawa
4. Geneva 1986
Answer
B. Alma-Ata
Alma-Ata 1978.
Which is an eligible couple register entry?
1. any unmarried adult
2. a married couple with a wife aged 15 to 49 years
3. couples with a child over 15 years
4. only couples with no children
Answer
B. a married couple with a wife aged 15 to 49 years
Eligible couples are those with the wife in the reproductive age group.
Td vaccine in the school-age schedule is given at:
1. 9 months
2. birth and 6 weeks
3. 2 and 5 months
4. 10 and 16 years
Answer
D. 10 and 16 years
Td replaces TT at 10 and 16 years.

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