ASHA-community health nurse collaboration for improving maternal and child health outcomes in India: a narrative review

Sneha Dixit; Valarmathi C.; Divya Trivedi; Gurupada K. P.; Ushakiran Thirunavukarasu; Pradeep Kumar; Khumbongmayum Chetanmala Devi; Ghanshyam Singh; S. Tongpangkokla Ozukum; Vidyashri R.; Deepa N. R.; Mohammed Umar

doi:10.18203/2394-6040.ijcmph20263244

Authors

Sneha Dixit Department of Community Health Nursing, College of Nursing, Rama University, Kanpur, Uttar Pradesh, India
Valarmathi C. Department of Child Health Nursing, K.G. College of Nursing, Coimnatore, The Tamil Nadu Dr. M.G.R. Medical University, Chennai, Tamil Nadu, India
Divya Trivedi Department of Community Health Nursing, DIT College of Nursing, DIT University, Dehradun, Uttarakhand, India
Gurupada K. P. Department of Community Health Nursing, Kodagu Institute of Medical Sciences Government College of Nursing, Rajiv Gandhi University of Health Sciences, Madikeri (Kodagu), Karnataka, India
Ushakiran Thirunavukarasu Department of Obstetrics and Gynaecological Nursing, Narayana College of Nursing, Dr. NTR University of Health Sciences, Nellore, Andhra Pradesh, India
Pradeep Kumar Department of Community Health Nursing, Saraswathi College of Nursing, Atal Bihari Vajpayee Medical University (ABVMU), Hapur, Uttar Pradesh, India
Khumbongmayum Chetanmala Devi Department of Community Health Nursing, College of Nursing, Regional Institute of Medical Sciences (RIMS), Manipur University, Imphal West, Manipur, India
Ghanshyam Singh Department of Community Health Nursing, Saraswathi College of Nursing, Atal Bihari Vajpayee Medical University (ABVMU), Hapur, Uttar Pradesh, India
S. Tongpangkokla Ozukum Department of Child Health Nursing, College of Nursing, IMDH Mokokchung, Nagaland University, Mokokchung, Nagaland, India
Vidyashri R. Department of Community Health Nursing, Shridevi Institute of Nursing Sciences, Rajiv Gandhi University of Health Sciences, Tumakuru, Karnataka, India
Deepa N. R. Department of Obstetrics and Gynaecological Nursing, ESIC College of Nursing, Rajiv Gandhi University of Health Sciences, Kalaburagi, Karnataka, India
Mohammed Umar Department of Nursing, Uttar Pradesh University of Medical Sciences, Saifai, Etawah, Uttar Pradesh, India https://orcid.org/0000-0001-8249-3803

DOI:

https://doi.org/10.18203/2394-6040.ijcmph20263244

Keywords:

Accredited Social Health Activist; community health nursing; maternal health; child health; primary healthcare; interprofessional collaboration

Abstract

India has achieved substantial progress in maternal and child health; however, preventable morbidity, mortality, inequitable access, delayed referral, and discontinuity of care remain important public health challenges. Accredited Social Health Activists and community health nurses occupy complementary positions within the primary healthcare system. Accredited Social Health Activists provide household-level mobilisation, counselling, surveillance, and linkage to health services, whereas community health nurses contribute clinical assessment, risk identification, skilled care, referral coordination, supervision, and continuity across community and facility settings. This narrative review examines how collaboration between these frontline cadres can improve maternal and child health outcomes in India. A structured literature search was undertaken using PubMed, Google Scholar, and relevant government and international health agency sources. Evidence suggests that effective collaboration can strengthen early pregnancy registration, antenatal care utilisation, identification of high-risk pregnancies, birth preparedness, institutional delivery, postnatal follow-up, home-based newborn care, breastfeeding support, immunisation, growth monitoring, and timely referral. However, fragmented communication, role ambiguity, hierarchical relationships, excessive workload, uneven supervision, delayed incentives, inadequate transport, weak referral feedback, and digital fragmentation limit the effectiveness of this partnership. This review proposes the CONNECT-MCH model, an integrated framework based on community identification, ongoing information exchange, nursing assessment and risk stratification, navigation and timely referral, escalation of high-risk cases, closed-loop continuity, and team learning with supportive supervision. Strengthening structured collaboration between Accredited Social Health Activists and community health nurses may transform parallel frontline activities into a coordinated continuum of care and improve equity, responsiveness, continuity, and accountability within India’s maternal and child health system.

References

Office of the Registrar General & Census Commissioner, India. Sample registration system (SRS)-special bulletin on maternal mortality in India 2021-23. New Delhi: Government of India; 2025. Available at: https://censusindia.gov.in/nada/index.php/catalog/46177/study-description. Accessed on 29 May 2026.

World Health Organization. Trends in maternal mortality 2000 to 2020: estimates by WHO, UNICEF, UNFPA, World Bank Group and UNDESA/Population Division. Geneva: World Health Organization; 2023. Available at: https://www.who.int/publications/i/item/9789240068759. Accessed on 29 May 2026.

International Institute for Population Sciences (IIPS), ICF. National Family Health Survey (NFHS-5), 2019-21: India. Mumbai: IIPS; 2021. Available at: https://iipsindia.ac.in/content/national-family-health-survey-nfhs-5-india-report. Accessed on 29 May 2026.

National Health Mission. About Accredited Social Health Activist (ASHA). New Delhi: Ministry of Health and Family Welfare, Government of India. Available at: https://www.nhm.gov.in/nhm/about-nhm/index1.php?lang=1&level=1&lid=226&sublinkid=150. Accessed on 29 May 2026.

Scott K, George AS, Ved RR. Taking stock of 10 years of published research on the ASHA programme: examining India's national community health worker programme from a health systems perspective. Health Res Policy Syst. 2019;17:29.

Ministry of Health and Family Welfare, Government of India. Indian Public Health Standards: Health and Wellness Centre-Sub Health Centre. Volume IV. New Delhi: Government of India; 2022. Available at: https://nhm.gov.in/images/pdf/guidelines/iphs/iphs-revised-guidlines-2022/04-SHC_HWC_UHWC_IPHS_Guidelines-2022.pdf. Accessed on 29 May 2026.

Agarwal S, Curtis SL, Angeles G, Speizer IS, Singh K, Thomas JC. The impact of India's Accredited Social Health Activist (ASHA) program on the utilization of maternity services: a nationally representative longitudinal modelling study. Hum Resour Health. 2019;17:68.

Saprii L, Richards E, Kokho P, Theobald S. Community health workers in rural India: analysing the opportunities and challenges Accredited Social Health Activists (ASHAs) face in realising their multiple roles. Hum Resour Health. 2015;13:95.

Chawla S, Kumar C, Bose M, Shrivastav SM. Performance and challenges of Accredited Social Health Activists (ASHAs) in delivering key maternal and newborn health services in India: a systematic review and meta-analyses. SSM Health Syst. 2025;5:100134.

Mishra A. 'Trust and teamwork matter': community health workers' experiences in integrated service delivery in India. Glob Public Health. 2014;9(8):960-74.

National Health Mission. ASHA module 6: simple skills that save lives. New Delhi: Ministry of Health and Family Welfare, Government of India. Available at: https://www.nhm.gov.in/images/pdf/communitisation/asha/book-no-6.pdf. Accessed on 29 May 2026.

Ministry of Health and Family Welfare, Ministry of Women and Child Development, Government of India. National guidelines for Village Health, Sanitation & Nutrition Day (VHSND). New Delhi: Government of India; 2019. Available at: https://www.nhm.gov.in/New_Updates_2018/NHM_Components/RMNCHA/CH/Guidelines/National_Guidelines_on_VHSND_English_High_Res_Print_ready.pdf. Accessed on 29 May 2026.

Blanchard AK, Ansari S, Rajput R, Colbourn T, Houweling TAJ, Isac S, et al. Understanding the roles of community health workers in improving perinatal health equity in rural Uttar Pradesh, India: a qualitative study. Int J Equity Health. 2021;20:63.

Blanchard AK, Colbourn T, Prost A, Ramesh BM, Isac S, Anthony J, et al. Associations between community health workers' home visits and education-based inequalities in institutional delivery and perinatal mortality in rural Uttar Pradesh, India: a cross-sectional study. BMJ Open. 2021;11(7):e048202.

Paul PL, Chellan R, Sahoo H. Association between maternal health service utilisation and institutional delivery in India: a secondary analysis of India Human Development Survey 2012. BMC Public Health. 2020;20:1071.

National Health Mission. Home based newborn care: operational guidelines (revised 2014). New Delhi: Ministry of Health and Family Welfare, Government of India; 2014. Available at: https://nhm.gov.in/images/pdf/programmes/child-health/guidelines/Revised_Home_Based_New_Born_Care_Operational_Guidelines_2014.pdf. Accessed on 29 May 2026.

Ministry of Health and Family Welfare, Ministry of Women and Child Development, Government of India. Home based care for young child (HBYC): strengthening of health & nutrition through home visits: operational guidelines. New Delhi: Government of India; 2018. Available at: https://nhm.gov.in/New-Update-2022-24/CH-Programmes/HBNC-%26-HBYC-Resource-%20Material/HBYC-Operational-Guidelines.pdf. Accessed on 29 May 2026.

Newton-Lewis TA, Bahety G. Evaluating the effectiveness of community health worker home visits on infant health: a quasi-experimental evaluation of Home Based Newborn Care Plus in India. J Glob Health. 2021;11:04060.

Dhaliwal BK, Gupta M, Nadda A, Singh S, Shet A, Scott K, et al. Urban community health workers in Punjab, India: a qualitative study of ASHAs' roles in the health system. PLOS Glob Public Health. 2025;5(8):e0003210.

Singh S, Tiwary B, Barik M, Arora H, Abraham SS, Majumdar P, et al. Knowledge of Accredited Social Health Activists in India: a systematic review and meta analysis of evidence drawn from primary studies published between 2005 and 2022. BMC Health Serv Res. 2025;25:58.

Gopalan SS, Mohanty S, Das A. Assessing community health workers' performance motivation: a mixed-methods approach on India's Accredited Social Health Activists (ASHA) programme. BMJ Open. 2012;2(5):e001557.

Tripathy JP, Goel S, Kumar AMV. Measuring and understanding motivation among community health workers in rural health facilities in India: a mixed method study. BMC Health Serv Res. 2016;16:366.

World Health Organization. WHO guideline on health policy and system support to optimize community health worker programmes. Geneva: World Health Organization; 2018. Available at: https://www.who.int/publications/i/item/9789241550369. Accessed on 29 May 2026.

Kok MC, Dieleman M, Taegtmeyer M, Broerse JEW, Kane SS, Ormel H, et al. Which intervention design factors influence performance of community health workers in low- and middle-income countries? A systematic review. Health Policy Plan. 2015;30(9):1207-27.

World Health Organization. Standards for improving quality of maternal and newborn care in health facilities. Geneva: World Health Organization; 2016. Available at: https://www.who.int/publications/i/item/9789241511216. Accessed on 29 May 2026.