Importance of Community Health Workers for Maternal Health Care Management

Objectives: Community Health Workers (CHWs) are important healthcare professionals and key members of team. The purpose of this research is to identify the roles and responsibilities of CHWs in developed and developing countries who provide healthcare assistance to pregnant and lactating women. Methods: For this particular study, a comparison was conducted between CHWs role in seven developed countries, seven South Asian developing countries, and India, with special emphasis on improving maternal health status. Results: CHW programs are essential in communities, institutional health programs, and outreach delivery systems. Without active community involvement, CHWs cannot reach their full potential. Developed countries have frameworks for CHWs, such as the Swasthya Shebika Program, Village Health Worker Cadret, Lady Health Worker Programme, and Accredited Social Health Activist program. CHWs are well-paid in developed nations and work with marginalized groups to spread health messages. However, up to 60% of community health workers in low- and lower-middle-income countries do not receive remuneration. Conclusion: Health systems must support CHWs in choosing technical interventions and providing necessary training, supervision, and logistical support.


INTRODUCTION
"Communities" are groups of people who may or may not live close to one another but who still hold the same beliefs, concerns, or identities as per WHO.These groups may be local, national, or international and may have narrow or broad interests.The term "community health worker" (CHW) refers to social service and/or public health professionals who work effectively with and for the community, promoting healthy lifestyles.They might provide paid or unpaid volunteer work for a nearby business, institution, or hospital.Similarities in race, language, culture, financial background, values, and life experiences exist between CHWs and the community individuals they serve.According to the US Department of Labour, CHWs are those who "help individuals and communities adopt healthy behaviors" and "conduct outreach" in addition to "advocating for people's individual and community health needs" [1].
Health of women during pregnancy, childbirth, and the postpartum period is referred to as maternal health.Every stage should be healthy in order to help women and children achieve their greatest potential for wellbeing.A shocking 287,000 women died during and after pregnancy and delivery in 2020, despite tremendous progress over the previous two decades [2].

METHODS
The present study "Importance of Community Health Workers for Maternal Health Care Management" is undertaken with the objective to understand nations perspectives regarding maternal healthcare.Also, to review the roles and responsibilities of community health workers and recognize the obstacles arising while reaching community health needs.
Maternal mortality rate is much higher in developing countries than in developed countries as presented in Figures 1A, B. For this reason, the methodology accepted for the particular study includes CHWs and their roles in seven developed countries and seven south Asian developing countries were compared in addition with Indian studies on contributing roles of community health workers in improving maternal health status.
All nations are divided into three groups based on their economics, according to the World Economic Situation and Prospects (WESP) classifications (2022): established economies, economies in transition, and emerging economies.Seven significant developed nations and South Asian developing nations were chosen for the current study.
Iran being a South Asian developing country was not purposely selected because its MMR is 22 per 100,000 live births.With a maternal mortality rate (MMR) reduction of 75% by 2015, Iran is one of the nations that has succeeded in fulfilling MDG5, having attained the largest reduction among its neighbors, with the exception of Turkey.Iran's MMR was 274 in 1975, dropped to 150 in 1990, continued to decline, and reached 94 in 1995, 38 in 2005, 30 in 2008, and 25 in 2015, a number comparable to developed countries [6,7].
A review of the many advancements made by the community health workers (CHWs) in basic healthcare is presented in this paper.This can be used as a valuable resource for learning about the work carried out by CHWs to ensure high-quality healthcare delivered to the target population by reviewing it.This literature review was conducted with the assistance of databases like PubMed, Google, and Google Scholar in order to gather a comprehensive amount of information.As part of this study, we investigated how CHWs are able to efficiently deliver vital healthcare services to the community.

RESULTS
In this section, Figures 1A, B show the maternal mortality ratio (modelled estimate, per 100,000 live births) as reported by WHO [2], UNICEF, UNFPA, the World Bank Group [8], and UNDESA/Population Division.
From the data presented in Figure 1 this is revealed that Iran being an developing country has MMR equivalent to developed countries.The 1920s saw the establishment of a sizable CHW programme in Ding Xian, China.At that time, Jimmy Yen, a Chinese community development specialist with experience teaching adult literacy, and Dr. John B. Grant, a Rockefeller Foundation employee assigned to Peking Medical University, trained illiterate farmers to keep birth and death records, administer smallpox and other disease vaccinations, give first aid and health education talks, and assist communities in keeping their wells clean [9].
The CHW projects in South Asia have a long history of being active, and the CHWs there still play a significant part in primary healthcare and serve as links between the community and the healthcare system.Countries in the region are simultaneously experiencing demographic and epidemiological changes, with populations that are getting older, more urbanized, and suffering from a greater burden of non-communicable diseases.In such a situation, it is vital to increase the contribution of CHW initiatives to PHC strengthening and fulfilling the region's objectives and aspirations.

Roles and Responsibilities of CHW
In this section, roles and responsibilities of Community health workers is discussed with special emphasis on their implementation in the community, training, salary and impact on the society.Seven major developed countries -Canada, Japan, France, Germany, Italy, United Kingdom and United States were selected to review the roles and responsibilities of CHWs in developed countries.The roles, responsibilities and implementation of CHWs in respective countries is presented in Table 1.
This can be summed from Table 1, that CHW in developed countries are provided with a framework to discuss their knowledge, challenges, resources and implementations to be applied to create a sustainable growth in terms of maternal health, child care and elderly support.Midwives along with other professionals are implemented to focus on pregnant and lactating women.
CHW are implemented by NHS (National Health Services) with the aim to reduce complications associated with pregnant and lactating women.Health professionals are organized under Ministry of health and run as universal public healthcare system.
In addition to professional education additional training of varied duration 3 months, 6 months or 1 year is provided to increase on job training experience.Various awareness programme are launched to increase knowledge regarding challenges faced by vulnerable group of people (pregnant mothers, lactating women, infants and elderly people).France offers comprehensive training for health careers, covering 5 years, including midwifery education in 35 schools across Europe.
Major role of CHW is shifted towards providing education, awareness and counselling regarding various health issues and non-communicable diseases to community members.HIV prevention, maternal-child and nutritional health promotion, oral health promotion for preschoolers, and facilitating marginalized communities' access to health services.Despite the fact that childbirths in Germany take place in hospitals, midwives are required to be present at every birth and can also provide services in women's homes.
CHWs reach out to marginalized populations with targeted programme and important health messages and are well-paid with good benefits.The expense of this care is covered by both statutory and private health insurance providers [10].CHW are paid by the management of organization depending on the sector whether public or private sector.Additional incentives and benefits are also provided.
Majority of CHWs are supervised by Ministry of Health.Various awareness and training programmes are implemented under the supervision of organizations to enhance the impact of CHW on beneficiaries.CHWs improve health outcomes by reaching marginalized communities, reducing health inequalities, and promoting quality care for women and newborns.They also reduce diabetes and hypertension risks through integrated care and awareness programs.
The background information, roles and responsibilities of CHWs in seven Sub Asian developing countries-Afghanistan, Bangladesh, Bhutan, Maldives, Nepal, Pakistan, Sri Lanka is presented in Table 2.   immunisation, NCD screening and health education, communicable disease prevention and promotion activities, reproductive health and family planning, prevention and surveillance for diarrhoea, and vector surveillance and control is regulated or coordinated by community health workers.CHW and VHW are voluntary cadres with limited monetary incentives for training and immunization campaigns.The MoH employs CHW and VHW as official government employees, with government compensation and non-financial incentives.LHWs earn $343 a year, with a stipend being crucial for family assistance.Compensation aligns with government salary structures, and they receive accommodation, maintenance, and allowances.
The MoH is responsible for policy formulation and implementation, while the (District Health Management Team) DHMT is responsible for providing health services and responding to local needs.Community Health Supervisors (CHSs) and Swasthya Kormis provide monthly supervision to health posts, while HAs train and supervise VHWs.However, poor supervision and monitoring due to insufficient funding, staff turnover, and geographical barriers hinder quality service provision and compliance with national guidelines.FCHVs are supervised by VHWs and MCHWs, while LHWs are affiliated with public health clinics and oversee them monthly.LHSs review work and create work schedules, while the MoH FHB monitors the implementation of RMNCH and PHM operations.Insufficient funding, shortages and turnover of technical and supervisory staff, and geographical barriers were some of the factors hampering the provision of regular supervision and monitoring [32].
CHWs have significantly contributed to Afghanistan's improved health status, reducing under-5 mortality and national TB control.Addressing gender imbalance in VHWs and improving employment conditions is crucial for female participation.Nepal has led the world in lowering maternal mortality, under-5 death rate, and fertility rates, while Pakistan needs to expand and strengthen its LHW Program for proper service coverage.Sri Lanka's health system has achieved high Human Development Index in 2019 and contributed to the attainment of the Millennium Development Goals.
The roles and responsibilities of CHWs in India is presented in Table 3 with special emphasis on Auxiliary Nurse and Midwife (ANM), Accredited Social Health Activist (ASHA), Anganwadi workers (AWW).
In India the National Rural Health Mission (NRHM) was developed in 2000 to improve rural PHC, accountability, and community engagement in the public health sector.In 2005, the Accredited Social Health Activist (ASHA) program was launched with motivating and recognition initiatives.The ASHA Facilitator is responsible for developing health reports and consolidating information about pregnancies, births, deliveries, newborn care, and deaths.By cultivating a sizable pool of CHWs known as Accredited Social Health Activists (ASHAs), the Indian National Rural Health Mission (NRHM) 2005 sought to enhance health outcomes.
Family planning, bringing expectant women to hospitals for birth, mother and child health, and health education are among the tasks.They travel with a first aid pack.ASHAs are assigned 200 families, with a total population of roughly 1,000 people, to work in both urban and rural regions.
A 23-day training programme meant to provide ASHA workers with the required knowledge and abilities.ASHAs are honorary volunteers given honorarium and performance-based incentives.States can design their own incentives, with some introducing fixed monthly honorariums.Starting 2018, ASHAs will receive a minimum of Rs. 2,000/-per month for routine activities, along with other task-based incentives approved at Central/State level.
All three workers are supervised individually.THe impact of ANM, ASHA and AWW is positive in nature.They promote better utilization of available schemes by the people.Also help in reducing MMR (Maternal Mortality Rate) and IMR (Infant Mortality Rate).

DISCUSSION
The evidence presented here indicates conclusively that CHW programs are not self-sustaining entities.Instead, they play a According to the 2006 World Health Report, countries that have fewer than 2.28 physicians, nurses, and midwives per 1,000 residents typically do not meet targeted 80% coverage for child immunization and competent birth attendance.The proportion of health professionals in the population and the survival of pregnant women and young children are directly correlated.Survival decreases proportionally when the number of health professionals decreases.The improvement of the nation's condition depends on the protection and promotion of women's health, that demands for a multisectoral plan of action.In developed countries, health services are provided with free comprehensive coverage to entire population irrespective of socioeconomic status in order to ensure equity in system.
The data show a noticeable rise in the number of healthrelated human resources, including midwives in Iran [37].Approximately 33,208 midwives work in the Iranian health system [37] at various levels of management (Ministry of Health and Medical Education at the policy making and management level), education (training midwifery undergraduates, masters, and doctorates, and health workers), and as a member of the healthcare team and under the supervision of obstetricians or general practitioners in health centers [38,39].Midwives are the largest group of healthcare providers in health centres in Iran [40].
CHWs in developed countries are provided with a framework to discuss knowledge, challenges, resources, and implementations for sustainable growth in maternal health, child care, and elderly support.They are essential components of the Basic Package of Health Services (BPHS) community-based healthcare section.Bangladesh, Bhutan, Sri Lanka, and India have established frameworks for CHWs, such as the Swasthya Shebika Program, Village Health Worker Cadret, Lady Health Worker Programme, and Accredited Social Health Activist (ASHA) program.
In developed countries CHW are implemented by National Health Service whereas in developed counties by Ministry of Health.Preventing unintended pregnancy is essential if maternal deaths are to be avoided.All women must have access to legal, safe abortion services as well as high-quality post-abortion care.As long as complications are managed or prevented, the majority of maternal deaths can be avoided.All women must have access to high-quality care during pregnancy, labor, and the postpartum period.The possibility that poor women in rural areas will receive adequate healthcare is the lowest [41].According to the most recent data, 99% of newborns in high-and upper-middle-income nations benefit from the presence of a qualified midwife, doctor, or nurse.But just 68% of low-income countries and 78% of lowermiddle-income countries receive such skilled assistance [42].
ASHA workers receive basic training, refresher training, and field experience in developing countries.They receive a 23-day program to provide knowledge and abilities.Community health workers, answerable to communities, represent the essential "missing link" between societal yearnings and communities in need.They receive interpersonal communication training, refresher training, and on-the-job training, with the 18-month training period unchanged since PHM abolition 93 years ago.
In developed nations, CHWs are well-paid with excellent benefits and work with marginalised groups to spread important health messages and specific programmes.Both public and commercial health insurance companies pay the cost of this care.Depending on the sector-public or private-CHW are paid by the administration of the organisation.There are also additional rewards and incentives offered.However, alternative estimates-those looking at all community health workers rather than just those performing services on behalf of the government-show that in developing countries, up to 60% of community health workers in low-and lower-middle-income countries did not receive any remuneration.In India, ASHA workers rely mainly on the incentive they receive by registering pregnant women for JSY (Janani Suraksha Yojana).
The following are some factors that discourage women from seeking or receiving care during pregnancy and childbirth: • Social determinants, such as income, access to education, race and ethnicity, that put some sub-populations at greater risk; • harmful gender norms and/or inequalities that lead to discrimination; and health system failures that lead to 1) poor quality of care, including disrespect, mistreatment, and abuse, 2) insufficient numbers of adequately trained health workers, 3) shortages of essential medical supplies, 4) the poor accountability of health systems.
Barriers to accessing high-quality maternal health treatments must be identified and removed at the health system and social levels in order to promote mother health in developing economy countries so as to achieve sustainable development goals.

TABLE 1 |
(India, 2023)ponsibilities of CHWs in major developed countries(India, 2023).Bangladesh has a history of using CHWs to support health services, with BRAC's Swasthya Shebika (SS) Program focusing on female health workers.Bhutan has a Village Health Worker (VHW) cadre, while Family Health Worker (FHW) and Community Health Worker (CHW) cadres work together.The Lady Health Worker Programme (LHWP) was established in 1994 to provide primary care services to underserved populations.In Sri Lanka, community health workers have two key frameworks: Public Health Midwife (PHM) and Public Health Inspector (PHI).Health centres, including health centres, employ a District Health Management Team (DHMT) and NGOs to implement BPHS.The MoH is responsible for policy formulation and implementation, while NGOs provide health services and support local needs.Family Health Workers (FHWs) are associated with health centres, providing outreach and house visits.In Pakistan, LHWs provide emergency care at their homes, with priority given to reproductive couples and children under five.Sri Lanka's midwife curriculum is based on WHO and ICM competency frameworks, covering family planning, nutrition Public Health Reviews | Owned by SSPH+ | Published by Frontiers February 2024 | Volume 45 | Article 1606803 CHWs are essential components of the Basic Package of Health Services (BPHS) community-based healthcare (CBHC) section.

TABLE 1 |
(Continued)Roles and responsibilities of CHWs in major developed countries (India, 2023).

TABLE 2 |
Roles and responsibilities of CHWs in Sub Asian Developing countries (India, 2023).

TABLE 2 |
(Continued)Roles and responsibilities of CHWs in Sub Asian Developing countries (India, 2023).
(Continued on following page) Public Health Reviews | Owned by SSPH+ | Published by Frontiers February 2024 | Volume 45 | Article 1606803

TABLE 2 |
(Continued)Roles and responsibilities of CHWs in Sub Asian Developing countries (India, 2023).

TABLE 3 |
Roles and responsibilities of CHWs in India (India, 2023).
Public Health Reviews | Owned by SSPH+ | Published by Frontiers February 2024 | Volume 45 | Article 1606803