Essential Care for Mothers and Newborns:
Pregnancy and Postpartum
Lesson Plan
Essential Care for Mothers and Newborns: Pregnancy
and Postpartum
Contents
Lesson 1: Antenatal Care and Health Facility Delivery ..................................... 6
Lesson 2: Maternal Care After Delivery ....................................................... 27
Lesson 3: Newborn Care Practices .............................................................. 37
Lesson 4: Family Planning ......................................................................... 48
Lessons 1-4 Pre and Posttest ..................................................................... 70
Lessons 1-4 Pre and Posttest ANSWERS...................................................... 73
Lessons, stories, and activities in the Essential Care for Mothers and Newborns:
Pregnancy and Postpartum Flipchart are explained in detail in this lesson plan.
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.
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.
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. In Lesson 1, we introduce the idea of an Activity
Leader who will focus on the needed materials for this module. 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 Volunteers 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 Volunteers of the next activity. Review the descriptions below
for more information.
2
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
Attendance and
Troubleshooting
Following the game, all facilitators take attendance.
The CHA follows up with difficulties that the
Volunteers had teaching the previous lessons as well as
problems they faced with their commitments from the
previous lesson. This is a good time to review the
content of the previous lesson.
Beginning in Lesson 2, the Activity Leader is responsible to organize materials
for the Lesson Activity. The Activity Leader will be elected in Lesson 1 of this
module. 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 (Volunteers or mothers)
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 asks about the current knowledge
and practices of the women in their group related to
the subject of the lesson. This helps the facilitator build
on what is already known and practiced by the
participants.
Ask about Current
Practices
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
3
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
Discuss Barriers
The facilitator asks if there are any obstacles that
prevent the caregivers from trying the new practices
discussed in the lesson. The facilitator and other group
members give more information or a different
perspective to help caregivers understand how to
overcome these obstacles.
Next is Practice and Coaching. We want to make
sure that each Volunteer understands the material and
can present it to her neighbors. The CHA observes and
coaches Volunteers as they practice teaching in pairs
using the flipcharts.
Practice and
Coaching
When Volunteers teach the mother group, they will
repeat this activity asking each woman to share the key
messages (and practices) that she has learned with the
woman next to her. The Volunteer will go around and
listen to each pair, making sure they understood the key
messages correctly.
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
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
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length although some lessons may take longer than others. The suggested time
for each section is listed below.
Section name
Game or Song
Attendance and Troubleshooting
Ask about Current Practices
Share the Meaning of Picture 2
Share the Meaning of Picture 3
Share the Meaning of Picture 4
Activity
Discuss Barriers
Practice and Coaching
Request Commitments
Time needed for this section
5 - 10 minutes
5 - 15 minutes
10 minutes
10 minutes
10 minutes
10 minutes
15-30 minutes
15 minutes
5 - 20 minutes
10 minutes
1 ½ - 2 ¼ hours
Many thanks to the illustrator, Tefero Tesfaye. 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-11-00012. 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:
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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
Central Statistical Agency Addis Ababa Ethiopia and ORC Macro.
Ethiopia Demographic and Health Survey (2011). Ethiopia: Calverton,
Maryland, 2011.
100 ways to energize groups: games to use in workshops, meetings
and the community. Available at www.aidsalliance.org.
International HIV/AIDS Alliance, 2002.
5
Lesson 1: Antenatal Care and Health Facility
Delivery
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Pregnant women will visit the health facility at least four times during
pregnancy.
Pregnancy women will receive an HIV test at the first sign of pregnancy.
Pregnant women will take iron/folic acid tablets each day with food during
pregnancy.
Pregnant women will receive a tetanus vaccination to prevent tetanus in the
mother and child.
Pregnant women will take one deworming pill after the fourth month of
pregnancy to prevent anemia.
Mothers will deliver their next child at the health facility with a skilled
provider (doctor, nurse of midwife).
Caregivers will be able to list at least two advantages of birthing at the health
facility.
o Women who birth at the health facility are more likely to survive
childbirth, recovery quickly and have a healthy child.
o
Experienced personnel with medical experience to help with life
threatening complications.
o
Women are able to rest away from their normal responsibilities.
o
Sterile and clean environment for birthing.
Caregivers will save money to pay for transportation costs and other
expenses for delivery at the health facility.
Materials:
1.
2.
3.
4.
5.
Attendance Register
Flipchart
Container of iron pills
Rocks or Leaves to use in the Activity
A mother’s health card
Summary:
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Game: People to People
Attendance and Troubleshooting
Ask the women about their experiences with antenatal care and delivery
at the health facility.
6
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Show pictures and share key message on flipchart pages 4-10:
Antenatal Visits, Tetanus and HIV, Prevent Anemia: Deworming and
Iron/Folate, Advantages of Delivery at the Health Facility, and Prepare
for Health Facility Delivery.
Activity: Delivery at the Health facility
Discuss Barriers
Practice and Coaching in pairs
Request Commitments
1. Game: People to People – 10 minutes
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, when 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
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group.
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their mother
group.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
7
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
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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?
7. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
8. Ask the group to select an Activity Leader who will be responsible to
coordinate the supplies and preparations for the activities in this module
starting with lesson 2. The Activity Leader 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 meetings ten minutes early so the CHA can give
her the list of needed items and 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. The
Activity Leader will also assist the CHA during the day’s activity.
9. Explain the needed items for the activity in Lesson 2. Help the Activity
Leader to gather these items with the help of the Volunteers for the next
meeting.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the mothers about their commitments from the last
meeting and follows up with those who had difficulty trying out new practices
(see the questions above).
5. Ask the group to select an Activity Leader who will be responsible to
coordinate the supplies and preparations for the activities in this module
starting with lesson 2. The Activity Leader will make sure that each mother
brings one or more of the needed items for the lesson’s activities. She will
come to each of the meetings ten minutes early so the Volunteer can give her
the list of needed items and 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. The
Activity Leader will also assist the Volunteer during the day’s activity.
8
6. Explain the needed items for the activity in Lesson 2. Help the Activity
Leader to gather these items with the help of the mothers for the next
meeting.
3. Ask about Current Practices
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Read the questions on page 4 of the flipchart.
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Where is the best place for a woman to delivery her child?
Why?
?
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Where did you deliver your last child?
What practices help women to have a healthy pregnancy
and delivery?
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. This activity is for LISTENING, not for teaching.
Ask the first question to hear the women’s knowledge about the best place to
give birth.
o It is likely that women will say delivery at the health facility is best.
Some however, may believe that home delivery is the best option for
them. Listen to the reasons for their answers.
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Ask the second question to hear where the women in your group delivered
their last child.
o Most women in Amhara deliver at home. However, if some women in
your group had a health facility health birth, ask them about their
experience.
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Ask the last question to listen for positive practices already known by the
women in your group.
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 visits, Tetanus and HIV – 10 minutes
4. Share the Meaning of Each Picture
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Ask the caregivers to describe what they see in the pictures on page 5.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 4 and 5.
9
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Show the women the mother’s health card you have brought. Show them
the place where the tetanus vaccinations are on the card. Encourage the
women to review their own cards and look to see if they have all five of their
tetanus shots.
Visit the health facility at least four times during pregnancy.
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Visit the health facility at the first sign of pregnancy.
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The health worker examines the mother to make sure the child
and mother are healthy.
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The health worker gives advice and pills for a healthy delivery
and birth.
To prevent tetanus, receive a tetanus vaccination during pregnancy.
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The vaccination will protect you and your unborn child from
tetanus.
Get an HIV test as soon as you know you are pregnant.
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Mothers with HIV need special care to prevent them from
passing HIV to their infant.
Additional Information for the Trainer
Antenatal Care in Ethiopia (2011) 1
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One out of every three pregnant women (33%) in Amhara receives antenatal
care from a skilled provider (doctor, nurse, or midwife). That leaves 67% of
women who do not!
Purpose of Antenatal Care
 Antenatal care helps to prevent poor pregnancy outcomes when it is started
early in the pregnancy (at first signs of pregnancy) and continued through
delivery.
 Early detection of problems in pregnancy leads to more timely referrals for
women in high-risk categories or with complications. Under normal
circumstances, the World Health Organization (WHO) recommends that a
woman without complications should have at least four antenatal care visits,
the first of which should take place during the first trimester (first three
months).
Tetanus in Adults
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1
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
Ethiopia Demographic and Health Survey (2011). Page 120
10
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.
Tetanus Vaccination
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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.
 In Amhara, less than half (43%) of pregnancies are protected from tetanus
toxoid.2
HIV, Malaria and Pregnancy
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HIV-infected pregnant women are at higher risk of malaria, anemia, and poor
birth outcomes including low birth weight, maternal death, and infant death.
Dual infection with malaria and HIV greatly increases the risk of maternal and
infant death.
It is very important for pregnant women to know their status. If HIV
positive, they should begin ARVs or infant prevention pills, and IPT treatment
(malaria prevention).
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Prevent Anemia: Deworming and Iron/Folate – 10 minutes
5. Share the Meaning of Each Picture
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Ask the caregivers to describe what they see in the pictures on page 7.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 6 and 7.
Show the container of iron pills to the mothers. Explain where they can
purchase (or receive) iron pills.
?
What do you think these pictures mean?
To prevent anemia, take one deworming pill after the fourth month of
pregnancy.
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Deworming pills kill worms in the body.
2
Ethiopia Demographic and Health Survey (2011). Page 119.
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Worms steal blood and food away from you and your infant!
Deworming improves the health of the mother and child.
Anemia (weak blood) in pregnancy is dangerous.
Anemia causes weakness, lack of energy and increases the risk of
the mother dying during childbirth.
Anemia can be caused by worms, malaria, and not eating foods
rich in iron such as meat and fish.
To prevent anemia, take one iron/folic acid pill each day of your
pregnancy with food.
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Iron pills strengthen a mother’s blood for a healthy pregnancy
and healthy child.
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Continue iron/folic acid pills for three months after pregnancy to
help you recover.
?
?
Do you remember the signs of weak blood (anemia)?
What are you doing to prevent anemia?
Additional Information for the Trainer
Iron/Folate Tablets
 Folate helps to prevent low birth weight and brain and spinal cord
abnormalities. If the pregnant woman does not have enough folate, the
infant’s brain and spinal cord do not grow propoerly. This often causes some
form of paralysis to the infant.
Iron and Deworming in Amhara
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In the Amhara region, only 19% of mothers took iron tablets and 6% took
parasite drugs during their pregnancy.
 Iron pills (also referred to as ferrous sulfate) should be available to pregnant
and lactating women at health facilities.
 Women should take iron pills daily, with food after their first prenatal visit
until four months after delivery.
 Women should take one deworming pill after their 4th month of pregnancy.
Anemia in Ethiopia
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Women with severe anemia are 3.5 times more likely to die during pregnancy
and childbirth than women without anemia.3 In Amhara 16.6% of pregnant
women are anemic.4
Advantages of Delivery at the Health Facility – 10 minutes
Brabin, B. J., Hakimi, M., and Pelletier, D. (2001). An analysis of anemia and pregnancy related
maternal mortality. Journal of Nutrition, 131(2S-2), 604S–614S
4
Ethiopia Demographic and Health Survey (2011). Page 184
3
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6. Share the Meaning of Each Picture
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Ask the caregivers to describe what they see in the pictures on page 9.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 8 and 9.
?
What do you think these pictures mean?
Women who deliver at the health facility are more likely to survive
childbirth, recover quickly and have a healthy baby.
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The health facility is a clean place for delivery.
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Clean beds and equipment prevent infection.
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Health workers have medicine and equipment to overcome
problems during delivery.
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Delivering at the health facility allows the mother to rest, away
from her responsibilities at home.
Women who deliver at home are more likely to suffer from infections.
Those with problems are not able to receive care in time.
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Delivering on a dirt floor increases the risk of infection.
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Germs on the hands of those helping with the birth increase the
risk of infection for the mother.
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Infants born too early or too small may not receive the care they
need to survive.
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Women with heavy bleeding or a birth complication may die
before they are able to get to a health facility.
?
What are some other reasons why delivering at the health facility is better
than delivering at home?
Additional Information
Delivery at the Health Facility
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5
6
Only one in every 10 women in Amhara delivers at a health facility.5
Delivering at the health facility ensures that the mother has good medical
attention and clean conditions during delivery which reduces the risk of
complications and infections that may lead to death or serious illness for the
mother and/or baby.6
Ethiopia Demographic and Health Survey (2011). Page 126.
Ethiopia Demographic and Health Survey (2011). Page 15.
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Prepare for Health Facility Delivery – 10 minutes
7. Share the Meaning of Each Picture
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Ask the caregivers to describe what they see in the pictures on page 11.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 10 and 11.
?
What do you think these pictures mean?
Save money to pay for transportation and costs related to delivery at the
health facility.
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Calculate how much money you will need.
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Calculate how much money you will need to save each week to
save all of the money you need.
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Keep this money separate from your spending money.
Discuss your delivery plan with your family.
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Share the importance of a health facility delivery.
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Ask the family to support you in the decision to delivery at the
health facility.
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Plan who will go with you to the health facility for the delivery
and to help you return home.
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Plan with your family who will take care of the household while
you are away.
Additional Information for the Trainer
Barriers to Health Facility Use
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7
Women in Amhara who did not deliver at a health facility were asked the
reasons they did not deliver in a health facility. The majority of women
(56%) said it was not necessary to delivery at a health facility, 36% said it
was not customary, 10% mentioned that the health facility was either too far
or that they did not have transportation.7
Since one in ten women in Amhara do not use a health facility because of the
difficulty of getting to a health facility, it is essential to discuss practical
options to help women go to the facility.
Ethiopia Demographic and Health Survey (2011). Page 128-129.
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8. Activity: Delivery at the Health facility – 15
minutes
1. Ask the mothers to compare birth at home to birth at the health facility.
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 facility).
3. Use rocks, leaves or other items to represent the advantages of each option.
4. Some advantages for birthing at the health facility 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).
e. More women (and their infants) die during home births than births at
the health facility.
5. Compare the advantages of birth at home versus birth at the health facility.
?
?
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 facility 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
facility. Encourage those who are not yet committed to birth at the health
facility to reconsider and discuss the idea with their family.
9. Discuss Barriers – 15 minutes
15
?
What do you think about these ideas? Is there anything that might prevent
you from trying these new health practices (or encouraging your wife to
adopt these practices)?
Ask mothers (or Volunteers) to talk to a woman (or other Volunteers) 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 (or Volunteers) to share what they have discussed with
the large group.
Help find solutions to their concerns. If a woman (or Volunteer) offers a good
solution to another woman’s (or Volunteer’s) concern, praise her and encourage
others to consider this solution.
10. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. (All Volunteers will work in pairs). Each Volunteer
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 Volunteer will teach the last two
pages of the lesson.
3. Watch, correct, and help Volunteers who are having trouble.
4. When everyone is finished, answer questions that the mothers have about
the lesson.
When the Volunteer is teaching the mother 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
16
?
Are you willing to make a commitment to the teachings you have heard
today? What is your commitment?
Ask each mother (or Volunteer) to say aloud a new commitment that she will
make today. Each mother (or Volunteer) can choose the commitment that is
most important to her.
For example:
 I commit to delivering my next child at the health facility or hospital.
 I commit to taking iron/folic acid pills every day during my pregnancy
and one deworming pill after four months of pregnancy (or supporting
my wife/family member to do this.)
 I commit to visiting the health facility at least four times during
pregnancy (or supporting my wife/family member to do this).
 I commit to talking with my husband about helping me find
transportation to the health facility (or talking to my wife/family member
to find transportation).
17
Lesson 2: Danger Signs during Pregnancy
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Women will go immediately to the health clinic if they see any of these
danger signs during pregnancy:
o Convulsions and fits
o
Fever
o
Fast or Difficult Breathing
o
Labor Pains for more than 12 hours
o
Vaginal bleeding
o
Severe headaches
o
Severe stomach aches
o
Unusual swelling of the face and hands
Pregnant women will begin saving money so they will have money to go to
the health facility if there is an emergency.
Materials:
1. Attendance Register
2. Flipchart
3. Rocks or leaves for the activity
Summary:
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Game: I’m Going to Have a Baby
Attendance and Troubleshooting
Ask the women about their knowledge and experiences with the dangers
signs during pregnancy.
Show pictures and share key message on flipchart pages 12-17: Danger
Signs During Pregnancy, Danger Signs and Saving for Emergency.
Activity: Making an Emergency Plan
Discuss Barriers
Practice and Coaching in pairs
Request Commitments
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1. Game: I’m Going to Have a Baby – 10 minutes
1. Ask the women to sit or stand in a circle with the facilitator.
2. This is a game of memory. The women in your group must remember
everything that the other women in the group say and repeat it.
3. The facilitator begins by saying, “I’m going to have a baby at the health
facility and I’m bringing … (adding something they will bring).”
4. There are no wrong answers in this game. The women can bring any item
they want to bring.
5. For example, “I’m going to have a baby at the health facility and I’m bringing
clean cloth.”
6. The woman to the facilitator’s right must repeat the phrase and add another
item. For example, “I’m going to have a baby at the health facility and I’m
bringing clean cloth and a papaya.”
7. Continue with each woman in the circle adding a new item to the list.
8. If a woman forgets or says the items in the wrong order, she must leave the
circle.
9. When there is only one woman in the circle the game is over.
Now let’s begin today’s lesson.
2. Attendance and Troubleshooting – 15 minutes
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group.
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their mother
group.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
19
?
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?
7. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
8. CHA asks the group’s Activity Leader to discuss the needed items for next
week’s activity and solicit volunteers.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the mothers about their commitments from the last
meeting and follows up with those who had difficulty trying out new practices
(see the questions above).
5. Volunteer asks the group’s Activity Leader to discuss the needed items for
next week’s activity and solicit volunteers.
3. Ask about Current Practices

Read the questions on page 12 of the flipchart.
?
?



What are the danger signs during pregnancy?
Have you ever experienced one of these signs? Tell me
about your experience.
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. This activity is for LISTENING, not for teaching.
Ask the first question to hear the women’s knowledge about the danger
signs.
Ask the second question to hear how the women usually respond when one of
these danger signs in seen.
20
o

Women may know the danger signs, but use local remedies to treat
them. Encourage the women to discuss how they treated the danger
signs (did they seek help? Did they use a local remedy) and also the
problems they may have encountered if they did not seek help.
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.”
Danger Signs During Pregnancy (page 1) – 10 minutes
4. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 13.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 12 and 13.
?
What do you think these pictures mean?
If you see these signs during pregnancy, go immediately to the health
facility!


Fever
Convulsions and fits
 Uncontrollable shaking and spasms may be a sign of
eclampsia (toxemia).

Fast of Difficult Breathing
 May be a sign of pneumonia or other chest infection

Labor Pains for more than 12 hours
 A sign the body is preparing for delivery.
Danger Signs during Pregnancy (Page 2) – 10 minutes
5. Share the Meaning of Each Picture
21



Ask the caregivers to describe what they see in the pictures on page 15.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 14 and 15.
?
What do you think these pictures mean?
If you see these signs during pregnancy, go immediately to the health
facility!
 Vaginal Bleeding
 Bleeding from the vagina may be in small amounts (spotting)
or in a large quantity.
?
?

Severe Headaches
 Headaches may be accompanied by blurred vision.
 Headaches may be caused by malaria or toxemia.

Severe Stomach pains

Unusual swelling of the face and hands
 Swelling in the legs and feet is normal.
 Sudden or severe swelling in the face and hands are the first
signs of eclampsia.8
Which of these danger signs have you experienced?
What did you do? If it were to see the danger sign again, what would you
do differently next time
Additional Information for the Trainer
Toxemia (Preeclampsia)
 Some swelling in pregnancy is normal especially of the legs and angles, but
swelling of the hands and face may be a sign of toxemia. The causes of
toxemia are unknown. Its symptoms include high blood pressure, swelling of
hands of hands and face and protein in the urine during pregnancy.
Danger Signs and Saving for Emergency – 10 minutes
6. Share the Meaning of Each Picture
8
Tesfaye, please replace with a commonly used name.
22



?
Ask the caregivers to describe what they see in the pictures on page 17.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 16 and 17.
What do you think these pictures mean?
If you



see a danger sign, go immediately to the health facility.
These are danger signs for you and your infant!
Don’t wait to see if the signs disappear.
Go immediately to the health facility for treatment.
Set aside money for an emergency.
 Save enough money to cover one emergency trip to the health facility.
 Add a small amount of money to cover some medicines and supplies for
one emergency trip to the health facility.
8. Activity: Calculating Savings – 15 minutes
1. Ask the mothers to list the costs of an emergency trip to the health facility.
2. Consider the following things:
a. Transportation costs
b. Costs for medicine
c. Costs for the a stay overnight (if clinic is very far)
d. Cost for food and care for family (those staying at home)
e. Other costs?
3. Calculate the approximate total costs of these items by adding them all
together. If costs range from 10 – 20 BIRR – use 15 as an average cost.
4. Use rocks or leaves to represent this amount of money.
a. For example if the total cost is approximately 15 BIRR, place 15 rocks
on the ground.
?
If you wanted to save 15 BIRR money in three months’ time, how much
would you need to save each month?
b. Encourage the women to divide the 15 rocks into three groups of the
same size.
c. This shows they would need to save 5 BIRR for three months in a row.
23
?
If you wanted to save 15 BIRR in five months’ time, how much would you
need to save each month?
d. Encourage the women to divide the 15 rocks into five groups of the
same size.
e. This shows they would need to save 3 BIRR each month for five
months in a row.
?
If you are pregnant now, when should you have your emergency fund ready?
o It is a good idea to have an emergency fund ready by the third or
fourth month of pregnancy.
Ask those women who are pregnant, if they have an emergency fund.
Encourage them to begin saving for one now.
?
If you are not pregnant now, should you have an emergency pregnancy
fund?
o It is a good idea to begin saving when you are not pregnant, so you
will have the emergency fund ready for your next pregnancy.
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 (or encouraging your wife to
adopt these practices)?
Ask mothers (or Volunteers) to talk to a woman (or other Volunteers) 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 (or Volunteers) to share what they have discussed with
the large group.
Help find solutions to their concerns. If a woman (or Volunteer) offers a good
solution to another woman’s (or Volunteer’s) concern, praise her and encourage
others to consider this solution.
24
10. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. (All Volunteers will work in pairs). Each Volunteer
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 Volunteer will teach the last two
pages of the lesson.
3. Watch, correct, and help Volunteers who are having trouble.
4. When everyone is finished, answer questions that the mothers have about
the lesson.
When the Volunteer is teaching the mother 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 (or Volunteer) to say aloud a new commitment that she will
make today. Each mother (or Volunteer) can choose the commitment that is
most important to her.
For example:
 I commit to teaching the danger signs to my family members.
 I commit to going immediately to the health facility if I see a danger
sign (or encouraging my wife/family member to do this).
 I commit to talking with my husband (or wife) about saving money with
me for an emergency fund.
25
26
Lesson 3: Maternal Care After Delivery






Within two days after delivery, women will return to the health facility with
their child.
After delivery, women will wash their genitals each day from front to back to
prevent infection and hurry healing.
After delivery, women will monitor their blood loss making sure they do not
bleed more than expected (more than 500 ml in one day).
Women who have delivered a child in the last two weeks will go to the health
facility 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
Bleeding more than expected (500 ml per day)
o
Reddish discharge that continues for more than two weeks
o
Leaking urine or stool
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 water often to stay healthy.
Caregivers will discuss methods to help mothers rest and share her work in
the weeks after delivery.
Materials:
1. Attendance Register
2. Flipchart
3. Bowl of 500 ml of water and cloth
Summary:








Game: I’ve Never
Attendance and Troubleshooting
Ask about the women’s knowledge and experience with postnatal care
Show pictures and share key message on flipchart pages 12-18: Health
Facility Visit, Infection and blood Loss, Mother’s Health and Nutrition, and
Danger Signs after Delivery.
Activity: Care After Delivery
Discuss barriers
Practice and Coaching in pairs
Request commitments
27
1. Game: I’ve Never – 10 minutes
1. Place enough mats for each woman to sit in a circle with no spaces between
them.
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 experienced. 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 spaces on the 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 never experienced.
5. The objective 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.
Now that we are energized, let’s begin our lesson.
2. Attendance and Troubleshooting – 15 minutes
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group
(beneficiary group).
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their mother
groups.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
28
?
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?
6. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
7. CHA asks the group’s Activity Leader9 to discuss the needed items for next
week’s activity and solicit volunteers.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the neighbor mothers about their commitments from the
last meeting and follows up with those who had difficulty trying out new
practices (see the questions above).
5. Volunteer asks the group’s Activity Leader to discuss the needed items for
next week’s activity and solicit volunteers.
3. Ask about Current Practices



Read the questions on page 18 of the flipchart.
?
What should a mother do after delivery to rest and
recover?
?
What did you do after your last delivery to speed your
recovery?
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. This page is for discussion, not for teaching.
Ask the first question to hear women’s beliefs about the practices that
encourage recovery after delivery.
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.
9
29


o
We hope the women respond this way: It is best for a woman to rest
often and work less than normal for up to six weeks after delivery. If a
especially important during the first week to reduce bleeding.
o
Eating an additional snack each day will help the women to recover
strength.
o
Taking an iron tablet each day with food helps a woman to recover
after delivery.
Ask the last question to find out the practices of the women in the group
after their last delivery.
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.”
Health Facility Visit – 10 minutes
4. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 19.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 17 and 18.
?
What do you think these pictures mean?
After delivery return to the health facility within two days.
 After delivery, mothers are in danger of severe illness from infection and
blood loss.
 Health workers can spot danger signs quickly and provide care for you
and your child.
 Health workers can treat infection and slow blood loss.
 If you are not able to walk, ask someone to help you.
?
Did you visit the health facility within two days after you last delivery?
Why or why not?
? Why or why not?
Additional Information for the Trainer
Maternal 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 die
30
within 24 hours after delivery, 23% of the deaths occur on days 2-7 after
delivery.10
Postnatal Care Amhara
 The majority of mothers in Amhara (93%) do not receive a postnatal
checkup. Among women who received a postnatal checkup, 4% were
examined within 4 hours of delivery with an additional 1% within 4-23 hours.
In total, only 5% of women received postnatal care within two days, as
recommended.11
Infection and Blood Loss – 10 minutes
5. Share the Meaning of Each Picture




Ask the caregivers to describe what they see in the pictures on page 21.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 20 and 21.
When teaching this page, dip a common cloth into a bowl of 500 ml of water
to demonstrate how much liquid is too much.
?
What do you think these pictures mean?
After delivery, wash yourself each day with soap (washing front to
back).
 Cleaning with soap kills germs and helps skin to heal.
 Rubbing from the back to the front may cause infection.
 Feces from the back may work into open wounds.
If you bleed more than expected, return to the health facility.

Talk with a birth attendant to find out how much bleeding to
expect.

Blood loss more than 500 ml in one day is too much.

500 ml is the amount of liquid in 8 coffee cups.

Pay someone to help transport you to the nearest health facility
immediately.

Without immediate treatment, your life is in danger!
?
How do women usually monitor blood loss?
10
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.
11
Ethiopia Demographic and Health Survey (2011). Page 129
31
?
How can a woman get quickly to the health facility if there is an
emergency?
Additional Information for the Trainer
Reasons for Maternal Death

The most common causes of maternal death after delivery are bleeding and
infection. Appropriate care in the first hours and days after delivery can
prevent the majority of these deaths.
Mother’s Health and Nutrition – 10 minutes
6. Share the Meaning of Each Picture



?
Ask the caregivers to describe what they see in the pictures on page 23.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 22 and 23.
What do you think these pictures mean?
For four weeks after delivery rest often; work less than normal.
 Women lose a lot of blood during and after delivery.
 A woman who loses too much blood is at risk of death.
 Resting often and letting the body heal slows and stops bleeding.
 Resting often helps the mother’s body to regain its strength.
Eat two additional snacks each day to gain strength after delivery.
 Eats beans, green leafy vegetables and organ meats for strong blood.
 These foods are rich in iron to give energy and strength.
 Additional foods help the mother to stay healthy while breastfeeding.
 Drink water often to stay healthy.
Danger Signs after Delivery – 10 minutes
32
7. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 25.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 24 and 25.
?
What do you think these pictures mean?
Quickly return to the health facility if you have any of these danger
signs.
 Fever
 Sharp belly pain.
 Fever and belly pain maybe be signs of infection inside the
belly.
 Many women die from untreated infections after delivery.
?

Reddish discharge for more than two weeks
 Discharge that does not stop after two weeks is a danger
sign.
 Bleeding more than 500 ml in one day is a danger sign.

Urine or feces leaking from the body
Why is it important to go immediately to the clinic?
Additional Information for the Trainer
Fistula

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.
 In most cases, surgery can repair these damages and help the woman to live
a normal life including the birth of more children. Women experiencing these
symptoms should go to a facility immediately.
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.
33

In general, women should go to the health facility if they do not feel “right”
or notice any unusual signs.
8. Activity: Care After Delivery – 15 minutes
1. Explain: In Ethiopia many women die during pregnancy or just after delivery.
2. Out of all the women that die between the ages of 15 and 49, one third of
them die because of problems during pregnancy, delivery or recovery.12 This
means that out of every 10 women who die, three of them die because of a
sickness related to their pregnancy or delivery.
3. Actions that we take to stay healthy can save lives. It can save your life and
mine.
?
What time is the most dangerous for mothers?
During delivery? Or after delivery?
Is it during pregnancy?
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.
Those who help women after delivery must know the danger signs. They can
watch mothers and help to get them to the health facility if there are
problems.
12
Maternal deaths account for 30% of all deaths to women age 15-49. Ethiopia Demographic and
Health Survey (2011).
34

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?
?
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.
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 (or helping your wife adopt these
practices)?
Ask mothers (or Volunteers) to talk to a woman (or Volunteers) 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 (or Volunteers) to share what they have discussed with the large
group.
Help find solutions to their concerns. If a woman (or Volunteer) offers a good
solution to another woman’s (or Volunteer’s) concern, praise her and encourage
others to consider this solution.
10. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. (All Volunteers will work in pairs). Each Volunteer
teaches in the same way that she was taught.
35
1. In each pair, one woman will teach the first two pages of the lesson to her
partner. After she is finished, the other Volunteer will teach the last two
pages of the lesson.
2. Watch, correct, and help Volunteers who are having trouble.
3. When everyone is finished, answer questions that the mothers have about
the lesson.
When the Volunteer is teaching the mother 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 (or Volunteer) to say aloud a new commitment that she will
make today. Each mother (or Volunteer) can choose the commitment that is
most important to her.
For example:




I will work less often in the six weeks after birth (or support my
wife/family member to do this).
I will visit the health facility within two days after birth (or support my
wife/family member to do this).
I will continue taking iron pills for three months after giving birth (or
support my wife/family member to do this).
I will share the danger signs with my family so they will know what to do
if I (or my wife/family member) am (is) having trouble after delivery.
36
Lesson 4: Newborn Care Practices




On the first day of life, mothers will not let their infant be washed with water,
but will make sure they are rubbed cleaned with a dry cloth.
After delivery, mothers will ask that their infant be placed skin to skin on
their chest to keep the newborn warm.
Mothers will encourage their child to begin breastfeeding within one hour
after birth.
Mother will refuse butter, water, juice and the giving of foods or liquids other
than breast milk after birth and for the first six months of life.
o 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.
o



Mothers will breastfeed not giving water, butter, juice or any other
foods or liquids to the infant other than breast milk.13
Caregivers will keep the umbilical stump clean and dry to prevent infection,
not allowing butter or anything else to be placed onto the umbilical stump.
Caregivers will not wash the infant in a basin of water until the umbilical
stump has fallen off.
Caregivers will take the newborn immediately to the health facility if any of
the following newborn danger signs are seen:
o Fever
o Difficulty breathing
o Difficulty feeding or refusing to eat
o Irritated stump with pus or blood
Materials:
1. Attendance Register
2. Flipchart
Summary:





13
Game: Rainstorm
Attendance and Troubleshooting
Ask the women about their knowledge and practices related to caring for a
newborn immediately after delivery.
Share the meaning of each picture using flipchart pages 20-27: Keeping the
Newborn Warm, Immediate Breastfeeding, Newborn Cord Stump Care and
Newborn Danger Signs.
Activity: Preventing Newborn Death
EBF and IBF were covered in Module 1. They will be reviewed here.
37



Discuss Barriers
Practice and Coaching in pairs
Request Commitments
1. Game: Rainstorm ─ 10 minutes
1. Ask the women to stand 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 woman 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 downpour!
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
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group.
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their neighbors.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
38
?
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?
7. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
8. CHA asks the group’s Activity Leader14 to discuss the needed items for next
week’s activity and solicit volunteers.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the neighbor mothers about their commitments from the
last meeting and follows up with those who had difficulty trying out new
practices (see the questions above).
5. Volunteer asks the group’s Activity Leader to discuss the needed items for
next week’s activity and solicit volunteers.
3. Ask about Current Practices
 Read the questions on page 26 of the flipchart.
?
What are the most important things a mother should to
keep her newborn healthy?
?
Which of these practices did you do? Why or why not?
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. This page is for discussion, not for teaching.
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.
14
39

Ask the first question to hear the women’s beliefs about care practices for a
newborn.
o We hope the women respond in this way: Placing the newborn skin to
skin is important for keeping the infant warm. Keep the umbilical
stump clean and dry prevents infection. Immediate breastfeeding
helps the child resist sickness and continuing to exclusive breastfeed
helps the child grow and develop to their full potential.

Ask the second question to review the women’s practices. Often women
know what to do, but don’t do it. Explore the reasons why women in your
group do not do the behaviors which they know are important.
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.”

Keeping the Newborn Warm - 10 minutes
4. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 27.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 26 and 27.
?
What do you think these pictures mean?
After birth, quickly dry the infant with a dry cloth.

Do not use water to wash the newborn for 24 hours.

Washing the infant with water will cause the newborn’s
temperature to drop quickly.

Do not rub away the white film on the baby’s skin. It protects
the skin.
Place the dry infant skin to skin on the mother’s chest to keep the child
warm.

Wrap a blanket over the child and around the mother.

The mother’s body will keep the infant warm.

The mother’s heart beating will calm the infant.

Place very small infants who are suffering, skin to skin for many
hours each day to help them survive.
40
Additional Information for the Trainer
Infant Heat Loss

Newborns are not able to maintain warmth as well as adults. They lose body
heat quickly if they are wet, uncovered, or exposed to cool air.
 Skin to skin contact is important for all infants, but especially the
underweight or preterm. The mother’s body temperature helps to regulate
the newborn’s body temperature, their heart rate and respiratory weight. It
also calms the infant and helps the infant initiate successful breastfeeding.
 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.15
Kangaroo Care
 Kangaroo care is a technique practiced on newborn, preterm infants. The
infant is held, skin-to-skin, with an adult for 20 minutes to four hours a day.
It is called Kangaroo Care because it is similar to the way a baby kangaroo is
snuggled against its mother.
 It has been found that keeping the infant skin to skin calms the infant, keeps
its body temperature stable, encourages early breastfeeding and infant and
mother well-being.
 In a study in Bogota Columbia, placing premature infants onto the mother’s
chest after birth and for several hours each day (as compared to infants kept
warm in incubators) decreased the mortality rate of premature infants from
70% to 30%.
15
2009 WHO/UNICEF Joint Statement, “Home Visits for the Newborn Child: A Strategy to Improve
Survival.”
41
Immediate and Exclusive Breastfeeding (Picture 4.3) - 10 minutes
5. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 29.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 28 and 29.
?
What do you think these pictures mean?
Begin breastfeeding within one hour after birth.

The mother’s thick milk (inger) gives the newborn protection
from illness like diarrhea and respiratory infection.

Offering the infant inger satisfies the infant and helps the
mother’s body to let go of the placenta.

Offering the infant inger helps slow the mother’s bleeding.

Offering the infant inger encourages the mother’s thin milk to
come.
Never give water, butter, juice or any other liquids other than breast
milk to an infant for six months.

Offering the child other foods and liquids increases the risk of
the child getting diarrhea.

Offering the newborn other foods and liquids means the infant
will suck less at the breast and your breast milk will reduce.

Breast milk provides enough food and water to satisfy all of
your infant’s needs!

Offering only breast milk is one of the best ways you can keep
your child healthy and alive.
Additional Information for the Trainer:
Immediate Breastfeeding and Prelacteal Feeds

In Amhara, only 38% of women interviewed said that their last child (born
within the last two years) received breast milk within the first hour after
birth; 67% said the child was breastfed within one day of birth. Another 48%
received a food or liquid other than breast milk during the first three days of
life.
Newborns and Hand washing
42

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.16
Hunger Signs and Umbilical Stump Care ─ 10 minutes
6. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the picture on page 31.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 30 and 31.
?
What do you think these pictures mean?
Breastfeed whenever the infant shows signs of hunger.
 The infant moves his tongue in and out.
 The infant sucks on his fingers or hands.
 The infant turns his head from side to side.
Keep the umbilical stump clean and dry. Do not put butter or anything
else on the stump.
 If urine or feces touches the stump, clean the stump with a damp soapy
cloth.
 Let it dry in the open air.
 Keep the umbilical stump dry. Do not wrap it with cloth.
 Applying butter will slow healing and cause infection.
?
?
?
?
Why do some mothers put butter on the umbilical stump?
What problems have you seen from this practice?
How can we encourage others to try this new practice?
Why isn’t crying listed as a sign of hunger?
 Children cry for many reasons.
 Children will always show a sign of hunger, before crying from hunger.
16
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 2008
43
Newborn Danger Signs ─ 10 minutes
7. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the picture on page 33.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 32 and 33.
?
What do you think these pictures mean?
Go immediately to the health facility if the newborn has any of these
danger signs.
 Too Hot or Too Cold
 Refuses to breastfeed
 Difficulty breathing: breathing too fast, too slow or gasping for breath
 Swollen, bleeding or umbilical stump with pus
 Swollen eyes or eyes with puss
 Yellow colored skin or eyes
 Has fits or convulsions
?
Have you ever seen one of these signs in a newborn? What happened?
Tetanus



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.
To prevent tetanus, pregnant women should receive a series of tetanus
vaccinations during pregnancy.
8. Activity: Preventing Newborn Death - 20
minutes
44
1. 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.
2. 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.
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?
3. 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 pregnancy
b. 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.
a. Visit the health facility 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.
b. Deliver at a health facility so health workers can use medicine and
equipment to hurry the delivery.
To prevent newborn infections.
a. Wash your hands before handling a newborn and after cleaning up
feces.
b. Keep the umbilical stump clean and dry.
c. Deliver at the health facility where health workers can treat infections.
45
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 (or helping your wife adopt these
practices)?
Ask mothers (or Volunteers) to talk to a woman (or other Volunteer) 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 (or Volunteers) to share what they have discussed with
the large group.
Help find solutions to their concerns. If a woman (or Volunteer) offers a good
solution to another woman’s (or Volunteer’s) concern, praise her and encourage
others to consider this solution.
10. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. (All Volunteers will work in pairs). Each Volunteer
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 Volunteer will teach the last two
pages of the lesson.
3. Watch, correct, and help Volunteers who are having trouble.
4. When everyone is finished, answer questions that the mothers have about
the lesson.
When the Volunteer is teaching the mother 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.
46
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 (or Volunteer) 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 refusing to let others give my child butter, water or any
foods or liquids other than breast milk for the first six months of life.
I commit to keeping my child’s umbilical stump clean and dry.
I commit to putting the infant skin to skin on my chest (or my wife’s
chest) after delivery.
I commit to waiting until the umbilical stump falls off to wash my child in
a basin of water.
47
Lesson 5: Family Planning





Mothers and fathers will delay new pregnancy for two years after the birth of
the last child.
Mothers and fathers will prevent new pregnancy using LAM:
o Exclusive breastfeeding for six months prevents pregnancy as long as
the infant is exclusively breastfed, the baby is less than six months
old, and the mother’s monthly bleeding has not returned.
Women will be able to identify the time of month when new pregnancy is
possible.
Mothers and fathers will talk with a health worker to choose a family planning
option to delay new pregnancy to use after LAM.
Mothers and fathers will believe that having children too close together puts
the mother at great risk of death during pregnancy and childbirth (increased
perceived severity).17
Additional Information for the Trainer and CHA
This lesson is designed for women. However these messages must be shared
FIRST with men and community leaders. Encourage community leaders to
share these messages with the men prior to teaching the women. Encourage
community leaders to be aware of the dangers to women and their children
when their wives become pregnant too soon.
Materials:
1. Attendance Registers
2. Flipchart
Summary:
 Game: The Sun Shines On
 Attendance and Troubleshooting
 Ask about family planning practices that are used by the women.
 Share the meaning of each picture using flipchart pages 28-33: Delaying New
Pregnancy, The Lactation Amenorrhea Method (LAM), and Health Facility
Options.
 Activity: LAM and the Four Women
 Discuss Barriers
 Practice and Coaching in pairs
 Request Commitments
17
Perceived severity is a behavioral determinant in barrier analysis: if women and their husbands believe that
maternal death is a severe outcome, they will take steps to avoid it. For more information visit
www.barrieranalysis.com.
48
1. Game: The Sun Shines On - 10 minutes
1. Ask the women to stand in a circle. The facilitator stands in the middle of the
circle.
2. The facilitator shouts, “The sun shines on…” and names a color or piece of
clothing that some of the women are wearing. For example, “The sun shines
on everyone wearing red.”
3. All the women wearing red must change places with one another. The
facilitator tries to take the place of someone who is moving. The facilitator
cannot squeeze into the circle in a new position; he must replace the spot of
a woman who has moved.
4. The person without a place to stand becomes the new facilitator and stands
in the middle of the circle.
5. The new facilitator shouts “The sun shines on…” and names a different color
or piece of clothing or characteristic.
6. Repeat the game so that many of the mothers have a chance to be in the
middle of the circle.
Now that we are energized, let’s begin our lesson.
2. Attendance and Troubleshooting – 15 minutes
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group
(beneficiary group).
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their neighbors.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
49
?
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?
7. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
8. CHA asks the group’s Activity Leader18 to discuss the needed items for next
week’s activity and solicit volunteers.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the neighbor mothers about their commitments from the
last meeting and follows up with those who had difficulty trying out new
practices (see the questions above).
5. Volunteer asks the group’s Activity Leader to discuss the needed items for
next week’s activity and solicit volunteers.
3. Ask about Current Practices
Read the questions on page 34 of the flipchart.


?
To keep women and children healthy, how long should
women wait after delivery before getting pregnant
again?
?
?
Are you ready to be pregnant again? Why or why not?
What methods are you using to delay new pregnancy?
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. You will correct their inaccurate beliefs in the flipchart pages
that follow.
Ask the first question to hear the women’s thoughts on the space between
needed for a healthy mother and child.
18
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.
50


Ask the second and third question to hear what methods women are using to
delay new pregnancy.
o Possible methods to delay new pregnancy may include the following:
the pill, condoms, LAM, and standard day methods, injectables,
implants, IUDs or traditional methods such as temporary abstinence or
withdrawal.
After the participants answer the last question, move to the next flipchart
page by saying, “Let compare your thoughts with the messages on the
following pages.”
Delaying New Pregnancy – 10 minutes
4. Share the Meaning of Each Picture



?
Ask the caregivers to describe what they see in the pictures on page 35.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 34 and 35.
What do you think these pictures mean?
Families that delay pregnancy for two years after each birth have healthy
mothers and healthy children.
 Mothers are healthy during and after pregnancy.
 Children grow healthy and strong.
 The parents have enough money provide good food and clothing for each
child.
Families that do not delay pregnancy suffer from poor health and sickness.
 Mothers and infants suffer from weakness and anemia (weak blood).
 Children of anemic mothers are born small and do not grow well.
 The parents do not have enough money to provide good food and clothing
for each child.
Additional Information for the Trainer
Child Death
 In Ethiopia children born less than two years after the preceding birth were
2.5 times more likely to die within the first five years of life as compared to
children born three years after the preceding birth.19
Birth Spacing in Ethiopia
19
Ethiopia Demographic and Health Survey (2011). Page 115.
51

In Ethiopia (2011) 20% of women had a child within 24 months of their last
delivery, 36% of births occurred 24-35 months after the previous birth and
44 percent are at least three years apart.
 The ideal birth interval 33 months or more between each birth.
Desire for Family Planning in Ethiopia
 In Ethiopia (2011) 38% of married women said they want to wait for two
years or more before having their next child.
 Thirty seven percent of married women want no more children.20
Miscarriage
 Women who have given birth to a dead child or had an abortion should wait
at least six months before becoming pregnant again.
Pregnancy of Young Women
 The most vulnerable births are those from women younger than 18 years
with a birth interval less than 24 months. These children are more than three
times as likely to die as children than children of older women with an
interval of 33 months or more.21
 To prevent infant death, families should delay first pregnancy until after the
woman is 18 years of age or older.
LAM (Lactation Amenorrhea Method) – 10 minutes
5. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 37 of
the flipchart.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 36 and 37.
?
What do you think these pictures mean?
The “LAM” method delays new pregnancy for six months if all of the
following things are true:
1. Monthly bleeding has not returned
2. The child is younger than six months
3. The child is never given water, porridge or other foods or
liquids.
20
21
Ethiopia Demographic and Health Survey (2011). Page 101.
Ethiopia Demographic and Health Survey (2011). Page 118.
52




All of these things must be true if you want to delay new pregnancy
using this method.
Bleeding is a sign that LAM will not work for you.
When your baby is six months, LAM will no longer delay new pregnancy.
If you give other foods and liquids, LAM will not work for you.
?
Are you able to use this method to prevent pregnancy? Why or why not?
?
What should you do if all of these things are not true?
o Talk with a health worker about other methods to delay new
pregnancy.
Additional Information for the Trainer
LAM definition
 LAM stands for the Lactation Amenorrhea Method. “Lactation” means
breastfeeding and “Amenorrhea” means not having monthly bleeding.
LAM Efficacy
 As commonly used, the LAM method is 98% effective in preventing new
pregnancies for up to six months. This means that if 100 women use LAM for
six months, only 2 women would become pregnant.22
Remember!

LAM only works if ALL of the criteria are true. Even if the woman’s bleeding
has not come, if any one of the following change, then the mother must find
a new method.
o Mother must give breast milk only, never giving water, beer, foods or
liquids.
o The child must be younger than six months.
o The mother’s bleeding has not returned.
Working Mothers

This method only works if the infant is fed whenever he is hungry (on
demand) day and night. If a woman is separated from her infant for more
than a few hours each day because of work or other responsibilities, the
effectiveness of this method is lowered and she should use a different
method.
Knowledge of Contraception in Ethiopia23
 Almost all of men and women interviewed have heard of a modern method of
contraception (98 and 97 percent, respectively). However only 3% of all
women and of all men interviewed have heard of LAM.
Planning Ahead– 10 minutes
22
Kennedy K. Labbok MH and Van Look PFA. 1996. Consensus statement: Lactational Amenorrhea
method for family planning. Int J Gynecol Obstet 54: 55-57.
23
Ethiopia Demographic and Health Survey (2011). Page 94 .
53
6. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 39.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 38 and 39.
?
What do you think these pictures mean?
Mothers using LAM must breastfeed whenever the child is hungry, day
and night.
Mothers using LAM must breastfeed even if you or your infant is sick.
 If you stop breastfeeding during sickness, new pregnancy is possible.
 If you stop breastfeeding during sickness, your child’s help grow worse.
 Breastfeeding during sickness is the best choice for your child.
While still using the LAM method, meet with a health worker to choose
the planning method you will use next.
 Monthly bleeding may return before your child is 6 months.
 Talk with your husband and the health worker about options to delay
new pregnancy.
 After six months, breastfeeding alone is not enough to prevent new
pregnancy.
 For those who are not able to use LAM, speak with a health worker to
find a method that works for you.
?
What other family planning options would you consider?
Additional Information for the Trainer
New Pregnancy / Fertility
 After birth, a woman may begin ovulating (becoming ready for new
pregnancy) as early as 25 days after the delivery.
Postpartum Bleeding


Bleeding that occurs 25 days after the child’s birth is considered a return of
monthly bleeding.
Bleeding that occurs before two months is most likely a result of normal postdelivery discharge.
54
Understanding Your Fertile Days – 10 minutes
6. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 41.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 40 and 41.
?
What do you think these pictures mean?
Each month, women bleed for some days and have secretions on some
days.
 After your monthly bleeding has returned for four months, your bleeding
should start coming regularly.
 All women have different schedules.
 This woman has four days of bleeding at the start of the month.
 Later she has some days of secretions.
 On the last day of the month her bleeding starts again.
New pregnancy is possible on days when secretions are present.
 If you have sex on days with secretions, new pregnancy is possible.
 If you use a condom on days when you have secretions you can delay
new pregnancy.
?
How do your secretions compare to this calendar?
Additional Information for the Trainer
Secretions
 Secretions may be slippery and thin or thick and sticky. Women do not need
to distinguish between the different types of secretions. All secretion is a
sign that new pregnancy is possible.
 Most women can tell the difference between semen and genital secretions.
Semen may be present on the woman’s genitals the morning after sex.
Checking for secretions in the afternoon and evening will help women to
avoid this problem.
 If women notice secretions for more than 14 days in a row, she may have a
sexually transmitted infection. She should visit the Centre de Santé for
diagnosis and treatment.
 On average, women will have 12-13 days each month when pregnancy is
possible.
Postpartum Women
 The calendar mucus method is recommended for women who have had four
months of monthly bleeding.
55

Secretions can be difficult to notice and interpret before four months of
bleeding. Women may have many days with secretions even on days when
new pregnancy is not possible. This increases the days that she and her
partner must abstain from sex, making the method more difficult to follow.
7. Activity: LAM and the Four women – 30
minutes
1. Tell the group about the following four women. Ask the group if this method
can be used by these women to prevent new pregnancy.
Mother 1, Aberash
This mother wants to delay pregnancy for two years. She has an infant that is
10 months old. She plans to breastfeed until the child is two years of age.
?
Will LAM protect her from a new pregnancy? (No. The child is too old)?
Mother 2, Alemitu
The mother has two children one is two months and the other is 20 months old.
She is breastfeeding both of them. She stops breastfeeding the oldest child,
but continues to exclusively breastfeed the youngest child.
?
Will LAM protect her from a new pregnancy? (Yes)
Mother 3, Abebech
She is breastfeeding her 3 month old infant and has never given porridge or
other foods to her infant. She does give some water to her infant each day.
?
Will LAM protect her from a new pregnancy? (No, she is giving the child
water.)
Mother 4, Sentayhu
She is exclusively breastfeeding her four month old infant. She has never given
her infant water, beer, or other foods or liquids. Today her monthly bleeding
returned. However her child is only four months old and she plans to continue
exclusively breastfeeding until six months of age.
56
?
Will LAM protect her from a new pregnancy? (No, her bleeding has
returned).
?
Will the LAM work for you? Why or why not?
Comparing Health Facility Options (Option 2)
Explain to the women that you want to speak openly about the different
methods that have been discussed.
? Which of the methods are the most effective at preventing new pregnancy?




Implants and IUDs are the most effective reversible methods. Ninety nine
out of 100 women are able to delay new pregnancy using these methods.
Surgery is very effective to prevent all future pregnancies.
LAM is very effective but only up to first six months and if all the criteria are
met.
Birth control pills are also effective if taken every day.
? Which methods require the least amount of time and attention?




Permanent methods require surgery and time afterwards to heal. After
healing, pregnancy will not be possible.
Implants and IUDs do not require women to do anything after they are put
in.
Injections require health facility visits every three months.
All other methods require daily attention, or attention before each sex act.
? Which method do prefer and why?
8. Discuss Barriers – 15 minutes
?
Is there anything that might prevent you from trying these new practices?
Ask Volunteers (and mothers) to talk to the person sitting next to them for the
next five minutes. They should share barriers and concerns they have about the
new teaching. Together they should try to find solutions to these barriers. After
five minutes, ask the Volunteers (and mothers) to share what they have
discussed.
57
Help find solutions to their concerns. If a Volunteer (or woman) offers a good
solution to another woman’s concern, praise her and encourage others to
consider this solution.
Possible concerns:
 Lack of transport / distance to the health facility for modern methods
o If this is a concern of the women, ask them if they can work together
to advocate with the community leaders to help them find a way to get
to the health facility easily.
9. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. She will use the first two flipchart pages of today’s
lesson.
2. Each Volunteer will teach the person next to them in the same way that the
CHA taught her.
3. After ten minutes, ask the women to switch roles. The other Volunteer will
share the teachings from the third and fourth pages of the lesson.
4. The CHA watches, corrects, and helps Volunteers who are having trouble.
5. When everyone is finished, answer any questions that the Volunteers have
about today’s lesson.
10. Request Commitments ─ 10 minutes
?
Based on today’s teachings, what commitment will you make?
Ask each mother to say aloud a new commitment that she will make today.
For example:
 I commit to talking with my husband (or talking with my wife) about going
with me to the health facility to discuss family planning options.
58


I commit to exclusively breastfeeding and using the LAM method for the first
six months of life as long as the three criteria are met (or encouraging my
wife to follow this method).
I commit to talking with my husband (or my wife) about delaying new
pregnancy for 2 years after my delivery.
59
Lesson 6: Health Facility Options for Family
Planning



Mothers and fathers will talk with a health worker to find out about other
family planning options to delay new pregnancy offered by the health facility.
o IUDs
o
Implants
o
Male and Female Condoms
o
Injections
o
Pills
o
Birth Control Pills
Mothers and fathers will discuss these options together and choose the option
which is best for them.
If after starting a new method, the woman does not feel well or has problems
related to the new method, she will return immediately to the health center.
Additional Information for the Trainer and CHA
This lesson is designed for women. However these messages must be shared
FIRST with men and community leaders. Encourage community leaders to
share these messages with the men prior to teaching the women. Encourage
community leaders to be aware of the dangers to women and their children
when their wives become pregnant too soon.
Materials:
1. Attendance Registers
2. Flipchart
3. (optional) Bring a new, unused male and female condom
4. (optional) Packet of birth control pills
Summary:
 Game: Taxi Rides
 Attendance and Troubleshooting
 Ask about family planning practices that are used by the women.
 Share the meaning of each picture using flipchart pages 42-50: Family
Planning Pills and Injections, IUD and Implants, Condoms and Standard Days
methods, and Health Facility Options.
 Activity: Health Facility Options
 Discuss Barriers
 Practice and Coaching in pairs
60

Request Commitments
1. Game: Taxi Rides - 10 minutes
1. Divide the women into small groups with an equal number of women in each
group. There should be at least three groups.
2. Each group should choose one taxi driver who "sits up front." The others
pretend to climb in the back behind the driver. The "driver" moves around as
if driving and the others in the car follow her.
3. The facilitator calls out a new number. The women must quickly make new
taxis with that number of people inside the car. Some women may have to
find a new car. Once a car is full with the number given by the facilitator, the
driver must quickly drive away. Women who are not in a car with the correct
number must leave the game.
4. The facilitator continues to call out new numbers. The women must quickly
make new taxis with that number. Those who are not able to enter a taxi (or
if a taxi does not have the correct number) must leave the game.
5. Continue until only one taxi is left.
6. Repeat the game as needed.
Now that we are energized, let’s begin our lesson.
2. Attendance and Troubleshooting – 15 minutes
When teaching Volunteers:
1. CHA fills out attendance sheets for each Volunteer and mother group
(beneficiary group).
2. CHA fills out vital events mentioned by each Volunteer (new births, new
pregnancies, and mother and child deaths).
3. CHA asks if any of the Volunteers had problems meeting with their neighbors.
4. The CHA helps to solve the problems mentioned.
5. CHA asks Volunteers to review the key practices from the last lesson.
6. The CHA asks the Volunteers about their commitments from the last meeting
and follows up with those who had difficulty trying out new practices.
61
?
What was your commitment at the last lesson? Have you kept that
commitment?
?
How – what did you do?



Did anyone (husband, grandmother or children) interfere or tell you not to
follow your commitments? Tell the story of what happened?
What factors (people, events or chores) in your life made it difficult to keep
your commitments?
How were you able to overcome these problems?
7. CHA thanks all of the Volunteers for their hard work and encourages them to
continue.
8. CHA asks the group’s Activity Leader24 to discuss the needed items for next
week’s activity and solicit volunteers.
When Volunteers teach their Neighbors:
1. Volunteers will take attendance.
2. Volunteers will ask about new births, pregnancies or illnesses in the families
of the mothers attending and help refer those with severe illness to the local
health facility.
3. Volunteer will ask the mothers to review the key practices from the last
lesson.
4. Volunteers will ask the neighbor mothers about their commitments from the
last meeting and follows up with those who had difficulty trying out new
practices (see the questions above).
5. Volunteer asks the group’s Activity Leader to discuss the needed items for
next week’s activity and solicit volunteers.
3. Ask about Current Practices
Read the questions on page 42 of the flipchart.


?
What family planning methods are available at the
health facility?
?
How far away is the facility? What are your thoughts
about his facility? Are you interested in using a health
facility method? Why or why not?
Encourage discussion. Don’t correct “wrong answers.” Let everyone
give an opinion. You will correct their inaccurate beliefs in the flipchart pages
that follow.
Ask the first question to hear about women’s knowledge of family planning
methods at the health facility.
24
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.
62
Possible methods to delay new pregnancy may include birth control
pills, condoms, LAM, injectables, implants, and IUDs.
Ask the second question to hear the women’s opinions about this health
facility.
o If women have a negative view of the health facility, we may need to
work with the women (or facility staff) to encourage an increase in use
of the facility.
o



Ask the last question to hear the women’s interest in trying an option from
the health facility. If some women in the group have tried some of the
methods, ask them to share their experience with the others in the group.
After the participants answer the last question, move to the next flipchart
page by saying, “Let compare your thoughts with the messages on the
following pages.”
Family Planning Pills and Injections – 10 minutes
4. Share the Meaning of Each Picture



?
Ask the caregivers to describe what they see in the pictures on page 43.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 42 and 43.
What do you think these pictures mean?
Take birth control pills each day to prevent new pregnancy.



Take one pill at the same time each day.
When you skip a day or miss a pill, new pregnancy is possible.
To delay new pregnancy, use one package of pills each month.
Receive an injection to prevent pregnancy for three months.
 For three months, new pregnancy is not possible.
 To delay new pregnancy, return every 12 months for a new injection.
 When a woman stops taking injections, it may take 3-6 months to become
pregnant again.
Additional Information for the Trainer
Use of contraception in Ethiopia25
25
Ethiopia Demographic and Health Survey (2011). Page 95.
63

Only 29 percent of currently married women report use of a contraceptive
method. The most common modern method used by each group of women is
injectables.
Pills and Injections
 When used correctly, pills and injections are 99.7% effective. This means
that if 100 women used these methods correctly for one year, none of them
would become pregnant.
 These methods prevent pregnancy by sending a chemical (hormone) that
stops the woman’s body from releasing eggs.
 These two methods may cause changes in monthly bleeding, headaches,
dizziness, mood changes, breast tenderness, abdominal pain, weight gain,
nausea and changes in desire for sex.
 After one year of regular injections, a woman’s monthly bleeding may be
infrequent or disappear altogether.
IUD and Implants – 10 minutes
5. Share the Meaning of Each Picture



?
Ask the caregivers to describe what they see in the pictures on page 45
of the flipchart.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 44 and 45.
What do you think these pictures mean?
Ask for a tube to be put under the skin to delay new pregnancy for three
years.
 The tube is called Implanon.
 When the tube is removed, new pregnancy is possible.
 Return every three years for a new tube.
Ask for an IUD to be put deep inside the body to prevent pregnancy for
ten years.
 The IUD is the shape of a T (or cross) and made of plastic or metal.
 It is placed in the womb (uterus).
 The IUD can be removed by a health worker to allow new pregnancy at
any time.
 The IUD must be removed or replaced every ten years.
?
not?
Would you be willing to try one of these methods? Why or why
64
Additional Information for the Trainer
Implant (Implanon)

Implants are one of the most effective and long lasting methods of delaying
pregnancy.
 It may change the woman’s monthly bleeding causing her to have infrequent
or no monthly bleeding. Some women may also have headaches, abdominal
pain and soreness in the breasts.
 Implanon prevents pregnancy by sending a chemical (hormone) that stops
the woman’s body from releasing eggs.
IUD (inserted device)
 IUDs are very effective in preventing pregnancy. They have been shown to
prevent pregnancy from 10-12 years, depending on the type of device used.
 It may cause prolonged and heavy bleeding in the first 6 months and
increased monthly cramping and pain.
 Women with low iron (anemia) should not use an IUD as heavy bleeding may
cause severe anemia. Return to the health facility if it feels like it is out of
place or is causing pain.
 The IUD prevents pregnancy by not allowing the man’s sperm to join with the
woman’s egg.
 The couple must keep track of the date that they received the IUD and have
it removed by a health worker. IUDS should be removed after ten years (5
years for copper-bearing IUD or 10 years for Levonorgestrel IUD).
Condoms and Standard Days Method – 10 minutes
6. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 47.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 46 and 47.
?
What do you think these pictures mean?
Use a condom every time you have sex, or on days when you have
secretions to delay new pregnancy.

Use a condom each time you have sex to prevent new
pregnancy.

On the 10-12 days when a woman has secretions, she is fertile.

Use a condom on days when you have secretions to prevent
new pregnancy.
65
Use condoms to protect yourself from HIV.

When one or more partners have HIV, use a condom to prevent
the spread of HIV.

If you and your partner have not been tested, use condoms
until you are sure.

Go with your spouse for an HIV test.
Use a calendar to help you identify your fertile days.

Ask a health worker to help you.

On days with secretions, use a condom or avoid sex.
?
Would you be willing to try one of these methods? Why or why not?
Additional Information for Trainers
Condoms

A male condom, when used consistently and correctly, is 80-95% effective in
preventing the transmission of the HIV virus. The female condom is believed
to offer the same level of protection as the male condom.
Health Facility Options – 10 minutes
6. Share the Meaning of Each Picture



Ask the caregivers to describe what they see in the pictures on page 49.
Read the captions on the flipchart out loud.
Share the meaning of each picture using flipchart pages 48 and 49.
?
What do you think these pictures mean?
Meet with a health worker to discuss the different options available to
prevent new pregnancy.
 The health worker can give advice and answer questions.
 Ask the health worker to explain any problems or changes in bleeding
caused by the methods.
After starting a new method, return to the health facility if you don’t feel
well.
 Some of these methods may cause headaches, nausea and changes in
monthly bleeding.
 If you are unhappy with one method, try another one.
66
?
?
?
How many of you have talked with a health worker about family planning
options?
Have you talked to your husband or family about family planning options?
What options interest you the most? Why?
Additional Information for Trainers
Condoms

A male condom, when used consistently and correctly, is 80-95% effective in
preventing the transmission of the HIV virus. The female condom is believed
to offer the same level of protection as the male condom.
7. Activity: Comparing Options – 30 minutes
Explain to the women that you want to speak openly about the different
methods that have been discussed.
?
Which of the methods are the most effective at preventing new pregnancy?
o Implants and IUDs are the most effective methods. Ninety-nine out of
100 women are able to delay new pregnancy using these methods.
o
LAM is very effective but only up to first six months and if all the
criteria are met.
o
Birth control pills are also effective if taken every day.
? Which methods require the least amount of time and attention?
o
Implants and IUDs do not require women to do anything after seeing
they are inserted.
o
Injections require health facility visits every three months.
o
All other methods require daily attention, or attention before each sex
act.
? Which method do prefer and why?
67
8. Discuss Barriers – 15 minutes
?
Is there anything that might prevent you from trying these new practices?
Ask Volunteers (and mothers) to talk to the person sitting next to them for the
next five minutes. They should share barriers and concerns they have about the
new teaching. Together they should try to find solutions to these barriers. After
five minutes, ask the Volunteers (and mothers) to share what they have
discussed.
Help find solutions to their concerns. If a Volunteer (or woman) offers a good
solution to another woman’s concern, praise her and encourage others to
consider this solution.
Possible concerns:
 Lack of transport / distance to the health facility for modern methods
o If this is a concern of the women, ask them if they can work together
to advocate with the community leaders to help them find a way to get
to the health facility easily.
9. Practice and Coaching ─ 20 minutes
1. Ask each Volunteer to share the teachings she has learned with the person
sitting next to her. She will use the first two flipchart pages of today’s
lesson.
2. Each Volunteer will teach the person next to them in the same way that the
CHA taught her.
3. After ten minutes, ask the women to switch roles. The other Volunteer will
share the teachings from the third and fourth pages of the lesson.
4. The CHA watches, corrects, and helps Volunteers who are having trouble.
5. When everyone is finished, answer any questions that the Volunteers have
about today’s lesson.
68
10. Request Commitments ─ 10 minutes
?
Based on today’s teachings, what commitment will you make?
Ask each mother to say aloud a new commitment that she will make today.
For example:
 I commit to talking with my husband (or talking with my wife) about the
different options for delaying new pregnancy.
 I commit to going to the health facility with my spouse to learn more about
family planning options.
 I commit to avoiding sex or using condoms on days when I (or my wife) am
(is) fertile.
 I commit to saving money so my spouse and I can afford a new method of
family planning.
69
Lessons 1-6 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 less than 75% (miss more than 3
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 facility for
antenatal care?
a.
b.
c.
d.
She should visit the health facility only when she feels sick.
She should visit the health facility every month.
She should visit the health facility at least four times before delivery.
She should go the health facility for antenatal care one day before
delivery.
2. Which of the following things will help the mother and child to be
healthy during delivery and birth?
a. A tetanus vaccination, taking daily iron/folate tablets and taking a
deworming pill once in pregnancy.
b. A measles vaccination, taking one vitamin A capsule and avoiding sex.
c. Taking daily deworming pills, getting a polio vaccination and drinking
animal milk.
d. Scheduling a hospital delivery, taking iron/folate tablets each day and
getting a measles vaccination.
3. Name two danger signs that signal a pregnant woman should go
directly to the health facility.
1. _________________________________________________________
2. _________________________________________________________
4. After seeing a danger sign, what should you do next?
a. Rest. After three hours, if the danger sign is still present, go to the
health facility.
b. Wait for your husband to return home. Ask him for the money you
need to go to the health facility.
c. Rest for one day. If the danger sign returns, go to the health facility.
d. Take the money you have in your emergency fund and go immediately
to the health facility.
70
e.
5. All of the following practices are recommended for woman after
delivery, except one. Choose the practice that is NOT recommended.
a.
b.
c.
d.
Take iron tablets each day for four months after delivery.
Drink water often to stay healthy.
Rest more often than normal.
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 facility.
1. _________________________________________________________
2. _________________________________________________________
7. Which of the following practices is the BEST way to help a newborn
stay warm?
a. Wrap the newborn in a wool blanket
b. Skin to skin contact against his mother’s chest
c. Place the newborn in an incubator
d. Wash the newborn in a basin of warm water
8. What
a.
b.
c.
d.
is the BEST way to help the umbilical cord stump heal?
Keep the umbilical stump dry and uncovered
Apply butter on the stump each day.
Wrap the newborn’s belly in a tight, clean cloth each day.
Pour water over the umbilical stump each day.
9. How many months should a mother wait after delivery before she
begins a new pregnancy? _________
10. Which criteria must be met for LAM to work properly? Choose ALL
that are correct.
a. Child must be younger than six months of age.
b. Child must be exclusively breastfed.
c. Child must be held skin to skin for at least one hour each day.
d. The mother’s monthly bleeding has not returned.
71
e. The child is given only breast milk and water.
11. In what days of the month is it possible to get pregnant?
a.
b.
c.
d.
All of them.
On days when the woman has bleeding
On days when the woman has secretions
On days when the woman has no bleeding and no secretions.
12. Name three different types of family planning methods.
1. _________________________________________________________
2. _________________________________________________________
3. _________________________________________________________
4. _________________________________________________________
72
Lessons 1-6 Pre and Posttest ANSWERS
1. How many times should a pregnant mother visit the health facility for
antenatal care?
C. She should visit the health facility at least four times before delivery.
2. Which of the following things will help the mother and child to be
healthy during delivery and birth?
a. A tetanus vaccination, taking daily iron/folate tablets and taking a
deworming pill once in pregnancy.
3. Name two danger signs that signal a pregnant woman should go
directly to the health facility.
Any two of the following are correct:
 Fever
 Fits or Convulsions
 Vaginal bleeding
 Severe Headaches or blurred vision
 Fast or difficult breathing
 Labor pains for more than 12 hours
 Severe Stomach Pains
 Unusual Swelling of the hands and Face
4. After seeing a danger sign, what should you do next?
d. Take the money you have in your emergency fund and go immediately
to the health facility.
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 facility.
Any two of the following are correct:





High fever
Sharp pains in the belly
Heavy bleeding (more than 500 ml in one day)
Reddish discharge that continues for more than two weeks
Urine or feces that leaks from the body
73
7. Which of the following practices is the BEST way to help a newborn
stay warm?
b. Skin to skin contact against his mother’s chest
8. What is the BEST way to help the umbilical stump heal?
a. Keep the umbilical stump dry and uncovered
9. How many months should a mother wait after delivery before she
begins a new pregnancy? _24 months or 2 years
10. Which criteria must be met for LAM to work properly? Choose ALL
that are correct. All of the following are correct.
a. Child must be younger than six months of age.
b. Child must be exclusively breastfed.
d. The mother’s monthly bleeding has not returned.
11. In what days of the month is it possible to get pregnant?
c. On days when the woman has secretions
12. Name three different types of family planning methods:
Any three of the following are correct:








LAM
IUD
Implants
Condoms
Avoiding sex on days when secretions are present
Birth Control Pills
Injections
Calendar Methods
74