essential nutrition, hygiene, and care practices during...

Essential Care for Mothers and Newborns:

Pregnancy and Postpartum Lesson Plan

Repeat Image 1.2C. Dr. Okitakoy if you use this image, please leave “Ir Leonidas Nisabwe” (Burundi) as one of the artists in the Acknowledgement page.

Repeat Picture 2.4D

Repeat Picture 3.2D Picture A. Repeat Picture 4.2A

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Essential Care for Mothers and Newborns: Pregnancy and Postpartum

Contents

Lesson 1: Antenatal Care and Danger Signs during Pregnancy.............................6Lesson 2: Preparing For Delivery and Birth..........................................................15Lesson 3: Importance of Postpartum Care...........................................................24Lesson 4: Newborn Care Practices.......................................................................35Lessons 1-4 Pre and Posttest...............................................................................45Lessons 1-4 Pre and Posttest ANSWERS..............................................................47

Lessons, stories, and activities in the Essential Care for Mothers and Newborns: Pregnancy and Postpartum Lesson Plan complement the information provided in the Essential Care for Mothers and Newborns: Pregnancy and Postpartum Leader Mother Flipchart.

Understanding the Lesson Plan

Each lesson begins with objectives. These are the behavior, knowledge and belief objectives that are covered in the lesson. Make sure that each of these objectives is reinforced during the lesson. There are four types of objectives. Each is described below.

Behavior objectives: Most objectives are behavioral objectives written as action statements. These are the practices that we expect the caregivers to follow based on the key messages in the flipchart.

Belief objectives: We know that beliefs and attitudes affect our practices. Many times it is a person’s inaccurate belief or worldview that hinders them from making healthy behavior change.

Behavioral determinant objectives: Behavioral determinants are reasons why people practice (or don’t practice) a particular behavior. There are eight possible behavioral determinants as identified in the Barrier Analysis1 surveys done in each region. The surveys identify the most important determinants for each behavior. By reinforcing the determinants that have helped the doers (caregivers in the community already practicing the new behavior) we are able to encourage the non-doers (caregivers who have not yet tried or been able to maintain the new practices). We also help non-doers (caregivers who are not practicing new behaviors) to overcome obstacles that have prevented them from trying or maintaining the practice in the past.

1 See http://barrieranalysis.fhi.net for more information.

http://barrieranalysis.fhi.net/

Under the objectives, all of the materials needed for the lesson are listed. The facilitator should make sure to bring all of these materials to the lesson. See below for more information.

Each exercise (section of the lesson plan) is identified by a small picture. Pictures are used to remind non-literate Leader Mothers of the order of the activities. For example when it’s time to lead the game the lesson plan shows a picture of people laughing as if they are enjoying a game (see below). The pictures in the lesson plan cue Leader Mothers of the next activity. Review the descriptions below for more information.

The first activity in each lesson is a game or song. Games and songs help the participants to laugh, relax and prepare for the lesson. Some games review key messages that the participants have already learned.

Game

Following the game, all facilitators will take attendance. The promoter follows up with any difficulties that the Leader Mothers had teaching the previous lessons.

Attendance and Troubleshooting

The Activity Leader meets with the facilitator ten minutes before each lesson to discuss the needed materials for the next lesson’s activity. The Activity Leader is responsible to talk with the others (Leader Mothers or neighbors) during the “Attendance and Troubleshooting” to organize the materials needed for the next meeting, asking them to volunteer to bring the items. The facilitator will lead the activity, but the Activity Leader will support her by organizing the volunteers and aiding the facilitator as needed during the activity.

Next the facilitator reads the story printed on the flipchart, using the images to share the story. The story in each lesson is followed by discussion questions.

Discussion questions are used to discuss the problems faced by the two main characters in the module (Mother A and Mother B). Use the story and discussion questions to find out the current practices of the women in the group.

Ask about Current Practices

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After turning to a new flipchart page ask, “What do you think these pictures mean?” After the participants respond, explain the captions and key messages written on the back of the flipchart.

Share the Meaning of Each Picture

The lesson plan also contains additional information for the trainer. The additional information does not need to be discussed during the lesson unless it relates to questions asked by the participants.

Next is an activity. Activities are “hands-on” exercises to help the participants understand and apply what they have learned. Most of these activities require specific materials and preparations which are organized by the Activity Leader.

Activity

The facilitator asks if there are any obstacles that prevent the caregivers from trying the new practices. The facilitator and other group members give more information or a different perspective to help caregivers understand how to overcome these obstacles.

Discuss Barriers

Next is Practice and Coaching. This section is required for the training of Leader Mothers only. We want to make sure that they understand the material and can present it to others. In this activity, the promoter observes and coach Leader Mothers as they practice teaching in pairs.

Finally, the facilitator requests a commitment from each of the women in the group. It is up to each woman to make a choice. They should not be forced to make a commitment if they are not ready.

Request Commitments

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All lessons follow the pattern described above. Lessons can be adapted as needed to fit the needs of your group. Lessons should not exceed two hours in length although some lessons may take longer than others. The suggested time for each section is listed below.

Section name Time needed for this sectionGame or SongAttendance and TroubleshootingStoryAsk about Current PracticesShare the Meaning of Picture 2Share the Meaning of Picture 3Share the Meaning of Picture 4ActivityDiscuss BarriersPractice and CoachingRequest Commitments

5 - 10 minutes5 - 15 minutes5 minutes10 minutes10 minutes10 minutes10 minutes15-30 minutes15 minutes5 - 20 minutes10 minutes2 – 2 ½ hours

AcknowledgementsMany thanks to the illustrators including (your local illustrator’s name), Ir Léonidas Nisabwe (Burundi), and Octávio Consalves (Mozambique). Games used in the lessons are available through the HIV/AIDS Alliance. See below for full details and resources used in the development of this module.

Suggested Citation: Hanold, Mitzi J. (2011) Essential Care for Mothers and Newborns: Pregnancy and Postpartum. Washington DC. Food for the Hungry (FH), made possible through support provided by the Office of Food for Peace, Bureau of Democracy, Conflict, and Humanitarian Assistances, and the U.S. Agency for International Development under the terms AID-FFP-A-?????. The opinions expressed herein are those of the authors and do not necessarily reflect the view of the U.S. Agency for International Development.

Resources used in the development of this module include the following: Beck, Diana, et al. Care of the Newborn: Reference Manual. DC: Save the

Children, 2004. Burns, A. August, et al. Where Women Have No Doctor. Berkley:

Hesperian Foundation, 1997. Available: http://www.hesperian.org/index.php

100 ways to energize groups: games to use in workshops, meetings and the community. Available at www.aidsalliance.org. International HIV/AIDS Alliance, 2002.

Lesson 1: Antenatal Care and Danger Signs during Pregnancy

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Pregnant women will visit the health center at least four times during pregnancy.

o Health workers will help mothers to remain healthy during pregnancy and will counsel mothers regarding conditions that may cause a difficult delivery.

o Women will visit the health clinic if they think they are pregnant, even if they are not having problems.

Caregivers will deliver their next child at the health center or regional hospital.

Caregivers will be able to list at least four advantages of birthing at a hospital or clinic.

o Experienced personnel with medical experience to help with life threatening complications.

o Sterile and clean environment for birthing. o Ability to give vaccinations to infants at birth.

Caregivers will go immediately to the health clinic if they see any of the pregnancy danger signs:

o Vaginal bleedingo Severe headaches o Severe stomach acheso Persistent vomiting

Materials:1. Attendance Register 2. Leader Mother Flipchart

Summary: Game: People to People Attendance and Troubleshooting Share the story and ask about current practices Show pictures and share key message on flipchart pages 6-11: Antenatal

Care during Pregnancy, Advantages of Delivery at the Health Facility and Danger signs during Pregnancy.

Activity: Delivery at the Health Center Discuss Barriers Practice and Coaching in pairs Request Commitments

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1. Ask each woman to find another woman and stand next to her. 2. Explain that the leader will call out actions and each pair must touch these

two body parts together. 3. For example, if the leader says, “Back to back” each pair must stand with

their backs touching. If the leader says, “Hip to Hip” each pair must stand with their hips touching. If the leader says, “Knees to Knees, each pair must stand with their knees touching. However, if the leader says, “People to People,” everyone must find a new woman to stand with.

4. Give many commands using different body parts. 5. Continue giving new commands using different body parts until the women

are laughing and having fun.

Now that we are energized, let’s begin our lesson.

2. Attendance and Troubleshooting – 15 minutes

1. Fill out the attendance sheets for each Leader Mother and neighbor group (beneficiary group).

2. Complete the vital events mentioned by each Leader Mother (new births, new pregnancies, and mother and child deaths).2

3. Ask the Leader Mothers if they had any problems teaching the last lesson. 4. Help solve the problems mentioned by the Leader Mothers. 5. Thank the Leaders for their hard work. Encourage them to continue.6. Ask the Activity Leader3 to discuss the needed items for next week’s activity

and solicit volunteers.

When the Leader Mother is teaching the neighbor group, she will use this time to take attendance.

Visiting the Health Center (Picture 1.1) – 10 minutes

2 Dr. Okitakoy are you tracking vital events? If not, please delete this part of ALL of the attendance and troubleshooting sections. 3 The Activity Leader should arrive ten minutes prior to each care group meeting to get the description of the activity and the list of needed items from the promoter.

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1. Game: People to People – 10 minutes

3. Story Read the story on page 4 of the flipchart.

The text below is copied directly from the flipchart. Once the flipchart is translated, paste the translated text into the box here.

Mother B sees Mother A walking along the path. “Where are you going?” Mother B asks. “I am going to the health center. The health worker will examine me to make sure the child is growing well.” Mother A says. Mother B says, “Growing well? I thought that only sick people went to the health center.”

4. Ask about Current Practices Read the questions on page 4 of the flipchart.

? Where is Mother A going? Why?? Why would she go to the health center if she is not sick?? How often did you visit the health center during your last

pregnancy?

Ask the first question to review the story.o Mother A is going to the health center. She is not sick, but is going so

the health worker can monitor her health and the health of the growing child in her belly.

Ask the second question to discuss the beliefs and practices of the women regarding visiting the health center.

o We hope the women respond in this way: Often people in the community go to the health center when they are ill. However, pregnant women and small children should go regularly to the health clinic.

o Health workers can find illnesses early before they become serious. When symptoms appear, it will take much longer to cure.

Ask the last question to find out how often women visited the clinic during their last pregnancy.

o At the moment that a woman knows (or believes) she is pregnant, she should visit the health center for her first visit.

o Pregnant women should visit the health center at least once each two months (at least four times before birth).

Encourage discussion. Don’t correct “wrong answers.” Let everyone give an opinion. This page is for discussion, not for teaching.

After the participants answer the last question, move to the next flipchart page by saying, “Let compare your ideas with the messages on the following pages.”

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Antenatal Care during Pregnancy (Picture 1.2) – 10 minutes

5. Share the Meaning of Each Picture

Ask the caregivers to describe what they see in the pictures on page 7. Share the meaning of each picture on flipchart pages 6 and 7. Use the captions on the flipchart to remind you which images represent each

point.The text below is copied directly from the flipchart. Once the flipchart is translated, paste the translated text into the box here.

? What do you think these pictures mean?

Visit the health center at least four times during pregnancy.o Go as soon as you know you are pregnant.

The health worker measures the growth of the mother and child.o If the infant is too small, she will give advice to help the infant

grow.o If the mother is too thin, she will give advice to help her gain

weight.

The health worker examines the mother for weak blood and other illnesses.o She looks for symptoms of malaria.o She looks for swelling in the hands and face.

The health worker looks for problems that might cause a difficult birth.o Poor position of the infant can put the mother at risk of death

during delivery.

? Do you think spending your time visiting the health center is a wise use of your time? Why or why not?

o Visiting the health center a few times may save your life or the life of your child.

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Advantages of Delivery at the Health Center (Picture 1.3) – 10 minutes



point.



The health center is a clean place for delivery.o Clean beds and equipment prevent infection.

Health workers have medicine and equipment to overcome problems during delivery.

o This woman has been in labor too long.o The health worker gives medicine to hurry delivery.

Health workers are able to give special care to weak or sick infants.o This newborn is not breathing.o They use special equipment to help the child breathe.o If this child were born at home, he might not survive.

Before leaving, newborns receive vaccinations to prevent illness.o This mother is sure that she and her infant are healthy.o The health worker will tell her when to return.

? What are some other reasons why delivering at the health center is better than delivering at home?

Danger Signs during Pregnancy (Picture 1.4) – 10 minutes

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point.



If you see any of the following danger signs, go to the health center.

Vaginal bleeding

Severe headaches

Severe stomach aches

Vomiting that won’t stop

o Even women who eat well and rest during pregnancy have difficulties.

o Don’t wait.o Go immediately to the health center for treatment.

8. Activity: Delivery at the Health Center – 15 minutes

1. Ask the mothers to compare birth at home to birth at the health center.2. Draw two columns on the ground. Above one column, draw an outline of a

house. Above the second column, draw an outline of a clinic (or cross for health center).

3. Use rocks, leaves or other items to represent the advantages of each option.

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4. Some advantages for birthing at the health center might include:a. There are specialists to help me if I have trouble.b. It is a clean environment for birthing.c. They can give the infant care immediately after birth if there is a

problem. d. They can easily give the needed vaccinations at birth (BCG and Polio).

5. Compare the advantages of birth at home versus birth at the health center.

? Which of these choices is best for the infant? ? Which of these choices is best for the mother?

6. Reinforce that birth at the health center is the safest place for both infant and mother. If there are problems, the health workers can work quickly and help the mother and infant recover. At home, if there are problems, the mother and infant are at higher risk of infection and death.

7. Discuss their concerns. Reinforce the advantages of birthing at the health center. Encourage those who are not yet committed to birth at the health center to reconsider and discuss the idea with their family.

9. Discuss Barriers – 15 minutes

? What do you think about these ideas? Is there anything that might prevent you from trying these new health practices?

Ask mothers to talk to a woman sitting next to them. They will share barriers and concerns they have about the new teaching. Together they will try to find solutions to these barriers. After five minutes, ask the women to share what they have discussed with the large group.

Help find solutions to their concerns. If a woman offers a good solution to another woman’s concern, praise her and encourage others to consider this solution.

10. Practice and Coaching ─ 20 minutes

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1. Ask each Leader Mother to share the teachings she has learned with the person sitting next to her. (All Leader Mothers will work in pairs). Each Leader Mother teaches in the same way that she was taught.

2. In each pair, one woman will teach the first two pages of the lesson to her partner. After she is finished, the other Leader Mother will teach the last two pages of the lesson.

3. Watch, correct, and help Leader Mothers who are having trouble.4. When everyone is finished, answer questions that the mothers have about

the lesson.

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When the Leader Mother is teaching the neighbor group, she will ask each woman to discuss the things she has learned with the woman sitting next to her. They will repeat the key messages that they have heard. They will do this in pairs. This will help them to verbally repeat the messages and clarify understandings.

11. Request Commitments ─ 10 minutes

? Are you willing to make a commitment to the teachings you have heard today? What is your commitment?

Ask each mother to say aloud a new commitment that she will make today. Each mother can choose the commitment that is most important to her.

For example: I commit to delivering my next child at the health center or hospital. I commit to visiting the health center once every three months for antenatal

care. I commit to going immediately to the health center if I see a danger sign.

? What was your commitment at the last lesson? Have you kept that commitment?

? How – what did you do?o Did anyone (husband, grandmother or children) interfere or tell you not

to follow your commitments? Tell the story of what happened?o What factors (people, events or chores) in your life made it difficult to

keep your commitments?o How were you able to overcome these problems?

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Lesson 2: Preparing For Delivery and Birth

Pregnant women will go immediately to the health center if they see one of the danger signs:

o When contractions are strong and come regularly (every 20 minutes). o Water comes from the vagina as if a bag of water has broken inside.o Bloody and sticky mucus comes from the vagina.

Caregivers will be able to describe what they should do during delivery.o Women will take long deep breaths to help the child birth.o When the child’s head begins to birth, the woman will take short quick

breaths with short pushes to help the child come slowly.o After the birth of the child, the umbilical cord will be tied after it turns

white. The cord will be tied in two places and cut with a new razor. o As soon as the newborn is dried, he will be placed skin to skin on the

mother’s chest.o Mother will begin breastfeeding immediately to help the placenta to

birth.

Materials:1. Attendance Register 2. Leader Mother Flipchart

Summary: Game: Musical Mats Attendance and Troubleshooting Share the story and ask about current practices Show pictures and share key message on flipchart pages 14-19: Signs that

Girth is Near, Delivery at the Health Center and Final Stages of Delivery. Activity: Making a Birth Plan Discuss barriers Practice and Coaching in pairs Request commitments

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1. Ask the women to stand in a circle with something to sit on (a chair or a mat behind them). The facilitator stands to the side.

2. Now remove one of the mats so that one person does not have a place to sit.3. Tell the women that you are going to sing a song. The women will walk

around the circle clapping and dancing as you sing. When you stop singing, they must find the closest mat and sit down. The woman who doesn’t find a seat must leave the circle.

4. The facilitator should turn his back (so he can’t see the women) and begin singing. Stop suddenly in the middle of the song. The woman without a mat leaves the game.

5. Remove one more mat. Then begin the song again with the remaining women.

6. Continue until there is only one mat and one woman left.







4 Dr. Okitakoy are you tracking vital events? If not, please delete this part of ALL of the attendance and troubleshooting sections.5 The Activity Leader should arrive ten minutes prior to each care group meeting to get the description of the activity and the list of needed items from the promoter.

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1. Game: Musical Mats - 10 minutes


Breaking Waters (Picture 2.1) – 10 minutes

3. Story Read the story on page 12 of the flipchart.


Mother B has decided to have her birth at the health center. She has prepared her supplies, put together food and water for after delivery, and talked with the neighbors about her plans. She is on her way to the market when a gush of water comes out of her. What is this? Is this a sign of labor?


? What happened to Mother B? What does it mean?

? Should she go to the health center or wait for another sign?

? What are the signs that you should leave for the health center?

Ask the first two questions to discover the women’s beliefs about labor.o The water is a sign that the bag which holds the child has broken. The

woman must deliver within one day from this time. If she waits too long, she and her child will develop infection and risk death.

o She should leave immediately so she arrives at the health center on the same day.

Ask the last question to find out what signs of labor are already known by the women.



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Sings that Birth is Near (Picture 2.2) – 10 minutes



point.



Clear water comes out of the vagina.o The infant is inside a bag of liquid in the mother’s belly.o When the bag breaks, liquid comes out of the body.

Clear or pink-colored mucus comes out of the vagina.o The bag which holds the infant is sealed with this mucus.o When the bag opens, the mucus comes out.o There may also be some blood.

Pains in the belly that are frequent, strong, and regular.o Pains will start slowly.o Pains will increase in number, strength, and length as time passes.o These pains begin to open the bag that holds the infant.

These are signs that birth is near. Go immediately to the Centre de santé.o Do not give medicine or put anything in the woman’s vagina to hurry

the birth.

Delivery at the Health Center (Picture 2.3) – 10 minutes

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point.



To help the child come, take long deep breaths.o The health worker will tell you when it is time to start pushing.o It may take from sun up to sun down for your body to be ready.o Pushing helps the infant’s head to birth.o Never push on the outside of the woman’s body to make the infant

come out.

When the top of the head appears, take quick, slow breaths.o This helps the head come slowly.o If the mother pushes hard and fast, she may tear.

After birth, quickly dry the infant’s head and body.o Wipe the mucus from the nose and mouth.o Dry the head and hair.

Additional Information for the trainerContractions It may take 10 to 20 hours for contractions to open the cervix (mouth of the

bag which holds the infant) during the first pregnancy. For a second or third birth, it may only take 7 to 10 hours.

The cervix is considered open when it dilates 10 centimeters. Once the cervix opens, the woman should start pushing.

Final Stages of Delivery (Picture 2.4) – 10 minutes

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point.



When the cord stops beating, tie it in two places.o The cord will turn white.o Tie it two, finger-widths away from the infant.o Add another tie two finger-widths away.

Cut the cord with a clean razor in between the two ties.o Always us a new razor.

Place the naked infant onto the mother’s naked chest. Cover them with a warm blanket.

o The mother’s body heat will warm and calm the infant.

Breastfeed immediately to help the placenta come out.o Never pull on the cord. It may break inside.o The nurse will tell you when to push.

Additional Information for the TrainerDelayed Clamping Delayed clamping (after the cord turns white) of the umbilical cord lessens

the risk of anemia in newborns. Placenta As the placenta separates from the womb, the cord will slowly come out of

the vagina. This is a sign that the placenta has separated and the woman can begin pushing to help the placenta exit.

If the placenta does not come out after the birth, and there is no bleeding, wait up to one hour for the placenta to come.

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8. Activity: Making a Birth Plan – 15 minutes

? Which of you have had a child at the health center? Please tell us about your experience.

? What are the things that a mother should bring with her to have a child at the health center?

Add any of the following things that were not mentioned: Clean clothing for the mother and newborn. A blanket Food and water for the mother to eat and drink during and after delivery Money for transportation to and from the health center

? What other things does a woman need to prepare before she leaves her home for the health center?

Add any of the following things that were not mentioned: Someone to watch her other children and feed the family Someone to come with her and help during the birth Someone to stay with her for one week after the birth

8. Ask each mother, “Do you have the supplies that you need for delivery? Do you know who will go with you to the health center?”

9. Discuss any questions they have about the birthing plan. Encourage those who have not already made a plan to start today.

10.Remind them that it is important to discuss this plan with everyone in the family and begin preparing for birth.



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the lesson.





For example:

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I commit to going to the health clinic when I see the signs that birth is near. I will gather food and water to take with me to the health center. I will ask the nurse to let me breastfeed immediately after the child is born.





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Lesson 3: Importance of Postpartum Care

Women who have delivered a child in the last six weeks will:o Rest more often than normal to help the body recover from the blood

loss and strain on the body from delivery.o Eat two additional snacks each day to regain strength after delivery.o Drink more liquids than normal to help the body recover and

encourage production of breast milk. Women who have delivered a child will go to the health center for vitamin A

and tetanus immunization in the first six weeks after giving birth. o Vitamin A helps improves the health status of the mothers and supplies

Vitamin A to the infant through breast milk for improved survival.o Mother will receive a tetanus vaccination if she has not received the

full treatment. Women who have delivered a child in the last two weeks will go to the health

center if one of more of the following danger signs are seen: o High fever and pain in the belly are all signs of infection. o Severe bleeding or bleeding that continues for more than two weeks o Leaking urine or stool is caused by long labor.

Caregivers will discuss methods to help mothers rest and share her work in the weeks after delivery.

Materials:1. Attendance Register 2. Leader Mother Flipchart3. A woman’s health card 4. Container of iron pills

Summary: Game: I’ve Never Attendance and Troubleshooting Share the story and ask about current practices: Mother B Goes Back to Work Show pictures and share key message on flipchart pages 23-27: Maternal

Care after Delivery, Services after Delivery at the Health center, and Danger Signs after Delivery.

Activity: Care After Delivery Discuss barriers Practice and Coaching in pairs Request commitments

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1. Place enough mats for each woman in a circle to sit. 2. Choose one volunteer. The volunteer stands in the middle. Her mat is

removed from the circle. 3. The volunteer names one thing that she has never experience. She should

think of something that others in the group have experienced. For example: “I do not have a male child, or “I have never been to the capital city.”

4. All of the women who HAVE a male child (or have been to the capital) must stand up and move to a new mat. At the same time, the volunteer tries to sit on one of the open mats. One person will be left without a mat to sit on. That person now stands in the middle and names one thing that she has experienced.

5. The object of the game is to stay in your seat. If you must move, move quickly into an open seat so that you will not have to stand in the middle.

6. Continue to play until everyone has a chance to stand in the middle.






and solicit volunteers.7. Ask the group to select a new Activity Leader who will be responsible to

coordinate the supplies and preparations for the activities in the next module. She will make sure that each volunteer brings one or more of the needed items for the lesson’s activities. She will come to each of the six meetings ten minutes early so the promoter can give her the list of needed items and


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1. Game: I’ve Never – 10 minutes

explain the activity for the next lesson. The Activity Leader will then ask for volunteers who are willing to bring the needed items during the “Attendance and Troubleshooting” section. She will also assist the promoter during the day’s activity. Choose a new Activity Leader when she completes six lessons.

When the Leader Mother is teaching the neighbor group, she will use this time to take attendance and select a new Activity Leader.

Mother B Goes Back to Work (Picture 3.1) – 10 minutes

3. Story Read the story on page 20 of the flipchart. The story encourages discussion about the importance of resting after

delivery.


Two days after delivery, Mother B begins her work again. In the morning, she sweeps her compound and goes to the market. In the afternoon, she begins preparing food, but she is not able to finish. She lies down and quickly falls asleep. Her son sees that her bleeding is heavy and runs for help.


? Why is Mother B bleeding?? How long should a woman rest after delivery?? How many days did you rest after delivery?

Ask the first questions to review the story.o We hope the participants will say: Mother B has not healed from her

delivery. She is working too hard. It increases her bleeding. Ask the second question to find out the beliefs of how long women should rest

(or is able to rest) after delivery. o It is best for a woman to rest often and work less than normal for up to

six weeks. If a mother is bleeding she must rest until her body is healed.

Ask the last question to find out how many days the women in the group rested.

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Maternal Care After Delivery (Picture 3.2) – 10 minutes



point.



Ask someone to stay with you after delivery for one week or more.o This woman lets Mother A rest.o She cooks for the family.o She cares for the children.

For six weeks after delivery rest often. Work less than normal.o Women lose a lot of blood during delivery.o Women who do not rest bleed more.o Work less until your body has healed.

Eat two additional snacks each day to gain strength after delivery.o This mother eats beans, lentils, green leafy vegetables and organ

meats, to make her blood strong.o These foods are high in iron.o Additional snacks help her to gain strength.o She drinks more water than normal to bring breast milk.

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? Is it difficult to rest after delivery?? Who can help the mother complete her work after delivery?? What advice would you give to a new mother about resting after delivery?

Additional Information for the TrainerMaternal Mortality Rate In developing countries, over half (60%) of maternal deaths occur in the

weeks after delivery. Of those who die after birth, most (45%) of them are within 24 hours after delivery. Another 23% of the deaths are on days 2-7 after delivery.8

The two largest reasons for maternal death are bleeding and infections. Appropriate care in the first hours and days after delivery can prevent the majority of these deaths.

Services after Delivery at the Health Center (Picture 3.3) – 10 minutes



point. Show the container of iron pills to the mothers. Explain where they can

purchase (or receive) iron pills. After reviewing the flipchart, point out the place on the health card where

tetanus vaccinations are marked.



Take iron pills each day for three months after giving birth.o Take iron pills with food.o Iron helps to make the mother’s blood strong.

8 Li, XF, Fortney, JA, Kotelchuck, M, and Glover, LH. 1996. The postpartum period: The key to maternal mortality. International Journal of Gynecology and Obstetrics 54(1): 1-10.

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o Iron gives energy and strength to the mother.

Receive Vitamin A in the first six weeks after giving birth.o The mother receives a drop of Vitamin A during her visit.o Vitamin A helps to restore the mother’s health.o Vitamin A in the mother’s breast milk helps the infant to resist

sickness.

Receive a tetanus vaccination if your card is not complete.o Tetanus causes lockjaw and painful convulsions.o Vaccinated mothers are protected from germs that may have entered

the body during delivery.o Breastfeeding infants are protected by drinking their mother’s milk.

? How many of you are taking iron pills?? How many of you have already received vitamin A?? Why are these services important?

Additional InformationIron Pills Iron pills (also referred to as ferrous sulfate) should be available to pregnant

and lactating women at health centers. Women should take iron pills daily, with food after their first prenatal visit

until four months after delivery. Vitamin A and Mortality It is estimated that 140-250 million children under five years of age have

vitamin A deficiency. These children suffer an increased risk of death, blindness and illness (especially measles and diarrhea).

Tetanus in Infants Tetanus germs grow in wounds or cuts that are contaminated by dirty

instruments or feces. Infants are at risk of tetanus if the umbilical cord is cut with an unsterilized instrument or if the stump is not allowed to dry and heal in the first week of life.

Signs of tetanus in newborns appear 3 to 10 days after birth. The child begins to cry continuously and is unable to suck.

Tetanus in Adults Mothers are at risk of tetanus from unclean deliveries or poor hygiene during

the postnatal period. A woman who has been vaccinated with five properly spaced doses is

protected for life. Infants born to this mother are protected for the first few weeks of life and then should receive the appropriate infant and child vaccinations which include tetanus.

An expectant mother whose tetanus immunization status is uncertain or whose last immunization was more than 10 years ago should be immunized against tetanus.

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Danger Signs after Delivery (Picture 3.4) – 10 minutes



point.



If you see any of these signs, go immediately to the health center.

Fever

Sharp pains in the bellyo These are signs of infection inside the belly.o Many women die from untreated infections after delivery.

Heavy bleeding or bleeding that doesn’t stop after two weeks.

Urine or feces leaking from the body.o If you see one of these signs, do not wait. Go to the health center.

? How does a woman know if her bleeding is heavy? What is the normal amount of bleeding after delivery?

? Why is it important to go immediately to the clinic?? Why is it important to go immediately to the clinic?

Additional Information for the TrainerFistula Leaking urine or feces is a sign that a tear has formed between the vagina

and rectum or the woman has a hole in the bladder or bowel. This is caused when labor goes too long and the skin dies between the vagina and anus.

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In most cases, surgery can repair these damages and help the woman to live a normal life including the birth of more children.

Additional Danger Signs Headaches, nausea, vomiting and feeling faint are signs of eclampsia

(toxemia). Calf pain, redness or swelling of calves; shortness of breast or chest pain may

be signs of a blood clot. In general, women should go to the health center if they do not feel “right” or

notice any unusual signs.

8. Activity: Care After Delivery – 15 minutes

1. Explain: In DRC, many women die during pregnancy or just after delivery. 2. Out of every 24 women will die because of problems during pregnancy,

delivery or recovery.9 (That means one of out every two care groups or neighbor groups is at risk of death from problems from pregnancy!)

3. Actions that we take to stay health can save lives. It can save your life and mine.

? What time is the most dangerous for this mother? Is it during pregnancy? During delivery? Or after delivery?

4. The majority of mothers die in the first seven days after delivery. This is the most important time for mothers to rest and recover.

? How many days is a mother usually given to rest after delivery? Is this enough?

? Is there someone watching if she shows a danger sign?? What are things that families can do to help women to recover after birth?

Some possible responses: Husbands can save a small amount of money (including transportation and

money for medication) in case the mother shows danger signs. The community can organize a vehicle for emergency trips to the hospital or

clinic. Husbands and older children can help with household work so the mother can

rest and breastfeed the newborn.

9 Estimates of Maternal Mortality 2008 (WHO/UNICEF/UNFPA/The World Bank). Available: http://www.childinfo.org/maternal_mortality_countrydata.php

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Those who help women after delivery must know the danger signs. They can watch mothers and help to get them to the health center if there are problems.

Old women in the community can volunteer to do field work for women who have recently given birth.

Ask each mother, “How can women help husbands and others in the community understand the importance of caring for the mother after delivery?”Ask each mother, “How can you help other mothers who have just delivered?”

Encourage the women to think of one thing they can do to raise awareness or help other women in the community after delivery.









the lesson.

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For example: I will work less often in the six weeks after birth. I will visit the health center for Vitamin A tablets after giving birth. I will continue taking iron pills for four months after giving birth.





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Lesson 4: Newborn Care Practices

Caregivers will not use water to clean the infant on the first day of life. o They will wait until the second day and use only a wet cloth. o Once the umbilical cord falls off and heals, they will wash the infant in

a basin every two or three days. Caregivers will keep the cord clean and dry to prevent infection.

o Caregivers will not place herbs or tobacco on cord which may increase infection.

Caregivers will wash their hands with soap and water before breastfeeding and after cleaning child feces.

Mothers will breastfeed the infant whenever the infant shows signs of hunger including sticking the tongue in and out; turning the head side to side or sucking on hands or fingers.

Caregivers will take the newborn immediately to the health center if any of the following newborn danger signs are seen:

o Fevero Difficulty breathingo Difficulty feeding or refusing to eato Irritated cord with pus or blood

Pregnant and breastfeeding women will believe that by breastfeeding and taking care of their infant they will be using their time and resources wisely.

Materials: 1. Attendance Register 2. Leader Mother Flipchart

Summary: Game: Rainstorm Attendance and Troubleshooting Share the story: Washing the Newborn Ask about current practices Share the meaning of each picture on flipchart pages 30-35: Washing the

Newborn, Newborn Care and Newborn Danger Signs. Activity: Preventing Newborn Death Discuss Barriers Practice and Coaching in pairs Request Commitments

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1. Game: Rainstorm ─ 10 minutes

1. Ask the Leader Mothers to sit quietly in a circle with their eyes closed.2. Their job is to listen to the sounds that are made by the woman sitting on

their right. They should repeat the sound that they hear from the woman sitting on their right.

3. The facilitator begins by rubbing her palms together to create the sound of rain.

4. The woman to her right makes this sound, and then the next woman until everyone in the circle is rubbing their palms together.

5. Once everyone is rubbing palms, the facilitator makes the rain sound louder by snapping her fingers.

6. The Leader Mother on her right repeats this sounds until one by one everyone is snapping their fingers.

7. Then the facilitator claps both hands together and the group joins in one by one.

8. Then the facilitator slaps her thighs and the group joins in one by one.9. Then the facilitator stomps her feet, the rain becomes a hurricane. 10.To indicate the storm is stopping, the facilitator reverses the order, thigh

slapping, then clapping, finger snapping, palm rubbing, and ending in silence.

Now that we are energized, let’s begin today’s lesson.

2. Attendance and Troubleshooting ─ 15 minutes






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Story: Washing the Newborn (Picture 4.1) ─ 15 minutes

3. Story: Read the story on page 28 of the flipchart.

Mother A gave birth to a girl a few days ago. She was named (insert name of Mother A’s child). After she returned from the clinic she rested at her mother’s house. She kept her child close to her body to keep her warm. Mother A’s mother says, “Let me bathe her in this basin.” “Not yet,” says Mother A. We must wait until her umbilical cord heals. If she sits in dirty water, it will bring sickness and infection.”


? How did Mother A care for her infant after birth?? Why did Mother A ask her mother to wait? Is this good

advice?? How and when did you bathe your infant after birth?

Ask the first question to review the story.

o She kept the infant warm by keeping her close to her body. Ask the second question to review the reasons Mother A did not want her to

be washed in a basin.o She was worried that washing her in a basin would cause infection to

the umbilical cord. o This is good advice as the water carries bacteria that can bring

sickness to the umbilical cord. Ask the last question to discuss bathing practices of the women in your

group.o We hope the women respond in this way: they dry the infant after

birth, not using water which will make the infant too cold. o On the second day of life they use a wet towel to clean the infant

and continue each day until the umbilical cord falls off. At that time they are able to wash the infant in a basin every two or three days.


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Washing the Newborn (Picture 4.2) - 10 minutes



point.


Dry the newborn well after birth. Do not wash with water on the first day.o Newborns have trouble keeping their body warm.o Water will make the newborn too cold.

On the second day, wash the infant with a wet cloth.o Wash the infant’s head, neck and around the eyes.o Wash inside the folds of skin on neck and legs.o Cover half of the infant’s body while washing to keep him warm.

Keep the cord clean and dry.o Do not put tobacco or plants on the cord.o If urine or feces touches the cord, wash it with soap.o Keep it dry. Do not wrap it with cloth.

After the cord falls off, wash the infant in a basin every two days.o The cord will fall off in 5 to 10 days.o If the cord has not fallen off, the water in the basin can cause

infection.

? How do these practices show that we are using the things God has given us wisely?

o If we take actions to prevent sickness and death, we are using our time and energy well.

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Additional Information for the TrainerInfant Heat Loss Newborns are not able to maintain their body temperature as well as adults.

They lose body heat quickly if they are wet, uncovered, or exposed to wind. Twenty five percent of an infant’s heat loss comes from the head. Cover the infant’s head with a hat or cloth to keep them warm for the first

three weeks of life. This prevents the risk of death from the infant’s body becoming too cold (hypothermia).

Infant Mortality Of all children who die under the age of five, 40% of them die within the first

28 days of life. Most of these deaths occur during the first 24 hours of life. There are three main causes of newborn death: infections, asphyxia (the infant does not receive enough oxygen before, during, or just after birth), and preterm births.12

Newborn Care (Picture 4.3) - 10 minutes



point.


Breastfeed whenever the infant shows signs of hunger.o The infant moves his tongue in and outo The infant sucks on his fingers or hands.o The infant turns his head from side to side.

Wash hands after cleaning the infant’s feces.o Newborns get sick very easily.o Keep infants healthy by keeping your hands clean.o Ask others to wash hands before holding the infant.

12 2009 WHO/UNICEF Joint Statement, “Home Visits for the Newborn Child: A Strategy to Improve Survival.”

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http://www.healthynewbornnetwork.org/resource/home-visits-newborn-child-strategy-improve-survival

http://www.healthynewbornnetwork.org/resource/home-visits-newborn-child-strategy-improve-survival

Sleep with the infant under a treated net each night.o Treated nets protect the infant from malaria.o Malaria is very dangerous for infants.

? What are other signs of hunger you have seen?

? Why isn’t crying listed as a sign of hunger?o Children cry for many reasons.o Hunger is only one of the reasons.o Children will always show signs of hunger, before crying from

hunger.

Additional Information for the Trainer: Newborns and Hand washing A study showed that newborns where birth attendants and mothers washed

hands before handling them had a 41% lower illness rate compared to newborns where mother and birth attendant did not wash hands.13

Hand Washing The most important times to wash hands are before preparing food or eating

and after using the latrine or cleaning child feces. Hand washing with soap is the most cost-effective way to prevent death and

disease from diarrhea. Hand washing before eating, preparing food and after using the toilet can reduce diarrhea in children by 50%.14 If soap is not available use ash.

13 Rhee V. et al. 2008. “Maternal and birth Attendant Hand Washing and Neonatal Mortality in Southern Nepal.” Archives of Pediatrics & Adolescent Medicine. Vol 162 (No. 7), pp 603-608. July 200814 Curtis, V., and S. Cairncross. 2003. “Effect of Washing Hands with Soap on Diarrhea Risk in the Community: A Systematic Review.” Lancet Infectious Diseases 3: 275–81.

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Newborn Danger Signs (Picture 4.4) ─ 10 minutes


Ask the caregivers to describe what they see in the picture on page 35. Share the meaning of each picture on flipchart pages 34 and 35. Use the captions on the flipchart to remind you which images represent each

point.


Go immediately to the clinic if you see any of these danger signs.

The infant has fever.

The infant has difficulty feeding or refuses to feed.

The infant has trouble breathing.

The umbilical cord is red or drips blood or pus.

? What other danger signs should a mother look for?o If you infant is not acting the way he normally does, go to the

health center.o If the infant has fits or convulsions.

8. Activity: Preventing Newborn Death - 20 minutes

5. The first 28 days of an infant’s life is the time when he is most vulnerable to germs, sickness, and death. Most of these newborn deaths happen on the first day of life. Let’s look at the reasons that newborns die.

6. Ask 10 women to stand up. These 10 women represent 10 newborns that die in the first month of life.

a. Ask three of the 10 women to stand together. These three women represent newborns that die because they were born too small or too early.

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b. Ask two of the remaining 7 women to stand together. These two women represent newborns that die because the delivery was very hard and the infants were not able to breathe well during or after delivery.

c. Ask two of the remaining 5 women to stand together. These women present newborns that die because of infections (germs that have gotten inside their bodies).

d. The last three women represent newborns that die from many other causes.

? Are you surprised by the reasons that infants die? Why or why not?

7. Spend the next five minutes encouraging the women to discuss practices to prevent the three main causes of newborn death.

Add any of the following practices that were not mentioned. To prevent infants born too small or too early.

a. Eat well during pregnancyb. Visit the antenatal clinic to monitor the size of the infant.c. Take iron pills every day during pregnancy.d. Sleep under a mosquito net (to prevent weak blood).e. Add a sprinkle of iodized salt to family foods.f. Eat a variety of foods – one from each food group.

To prevent infants not being able to breathe.g. Visit the health center four times before birth so they can monitor the

growth and position of the infant. If the infant is turned, labor may be too long causing him to suffer.

h. Deliver at a health center so health workers can use medicine and equipment to hurry the delivery.

To prevent newborn infections.i. Wash your hands before handling a newborn and after cleaning up

feces.j. Keep the umbilical cord clean and dry.k. Deliver at the health center where health workers can treat infections.

9. Discuss Barriers ─ 15 minutes


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the lesson.





For example:

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I commit to washing my hands after using the latrine or cleaning up child feces.

I commit to breastfeeding whenever my child shows signs of hunger. I commit to waiting until the umbilical cord falls off to wash my child is a basin

of water.





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Lessons 1-4 Pre and Posttest

Two questions from each lesson are listed below. Before and after teaching the materials to staff and trainers, give the posttest to evaluate their comprehension. For those who score 75% or less (must have at least 9 correct answers), give them more training to help them understand the information. Trainers should not teach others until they are able to score 75% or better.

1. How many times should a pregnant mother visit the health center for antenatal care?

a. She should visit the health center only when she feels sick.b. She should visit the health center every month.c. She should visit the health center at least four times before delivery.d. She should go the health center for antenatal care one day before

delivery.

2. Name two advantages of having a child at the health facility.

__________________________________________________________________________________________________________________

3. Name two signs of labor (the birth of the child is near). These signs tell the mother she should leave quickly for the health center. __________________________________________________________________________________________________________________

4. All of the following practices are recommended for woman after delivery, except one. Choose the practice that is NOT recommended.

a. Take iron tablets each day for four months after delivery.b. Within six weeks, go for a vitamin A tablet.c. Rest more often than normal. d. Eat less food than normal.

5. Name two danger signs after delivery. If a mother has these signs, she needs to be taken immediately to the health center.

__________________________________________________________________________________________________________________

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6. When should the umbilical cord be cut?a. As soon as the infant is delivered.b. After the cord stops pulsing and turns white.c. Before the infant begins breastfeedingd. After the placenta (infant’s feeding bag) is delivered.

7. On what day can you use a wet cloth to wash a newborn?a. On the first dayb. On the second dayc. On the third day when the white milk comesd. On the 10th day when the umbilical cord falls off.

8. Name two signs that a newborn gives to show that he is hungry.____________________________________________________________________________________________________________________________________

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Lessons 1-4 Pre and Posttest ANSWERS

1. How many times should a pregnant mother visit the health center for antenatal care?C. She should visit the health center at least four times before delivery.

2. Name two advantages of having a child at the health facility.

Any two of the following are correct: The health center is a clean place for delivery The health center has equipment to help with problems during delivery The health center has medication to help with problems during delivery Health workers have experience solving problems during delivery Health workers are able to give vaccinations to newborns.

3. Name two signs of labor (the birth of the child is near). These signs tell the mother she should leave quickly for the health center. Any two of the following are correct: Water released from the vagina Contractions that are strong, regular and close together. Mucus comes from the vagina

4. When should the umbilical cord be cut?B. After the cord stops pulsing and turns white.

5. All of the following practices are recommended for woman after delivery, except one. Choose the practice that is NOT recommended.

D. Eat less food than normal.

6. Name two danger signs after delivery. If a mother has these signs, she needs to be taken immediately to the health center.

Any two of the following are correct: High fever Sharp pains in the belly Heavy bleeding or bleeding that continues for more than two weeks Urine or feces that leaks from the body

7. On what day can you use a wet cloth to wash a newborn?B. On the second day

8. Name two signs that a newborn gives to show that he is hungry.Any two of the following are correct:

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He moves his tongue in and out and makes sucking noises. He sucks on his fingers. He opens his mouth and turns his head from side to side. He cries.

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essential nutrition, hygiene, and care practices during...

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