MATERNAL AND NEONATAL HEALTH
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MATERNAL AND NEONATAL HEALTH
COMMUNITY BASED MATERNAL AND
NEONATAL CARE
MANUAL FOR HEALTH SURVEILLANCE
ASSISTANTS
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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MATERNAL AND NEONATAL HEALTH
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WHO logo
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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TABLE OF CONTENTS
ABBREVIATIONS
FOREWORD
ACKNOWLEDGEMENTS
THE USER OF THE MANUAL ............................................................................................... 8
1. 1 BACKGROUND INFORMATION .............................................................................10
1. 1.1: SITUATION OF MATERNAL AND NEWBORN HEALTH IN MALAWI...................... 11
1. 1: INTERPERSONAL COMMUNICATION ....................................................................18
SUB-UNIT 3.2 IMMEDIATE CARE OF THE BABY IMMEDIATELY AFTER BIRTH .................. 53
4.1 TEMPERATURE AND RESPIRATIONS ..........................................................................56
TAKING TEMPERATURE: SKILLS CHECKLIST.....................................................................57
SUB-UNIT 4.2 BREAST FEDING ......................................................................................... 59
4.2
Exclusive Breastfeeding: ...................................................................................... 66
SUB-UNIT 4.3 IDENTIFICATION AND MANAGEMENT OF LOW BIRTH WEIGHT BABIES..74
4. KANGAROO MOTHER CARE (KMC) METHOD ......................................................... 78
SUB UNIT 4.5 POSTNATAL HOME VISITS ........................................................................82
UNIT 5: MANAGEMENT OF SUPPLIES, RECORD KEEPING, SUPERVISION
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ABBREVIATIONS
AFASS
AIDS
ANC
APH
ART
ARV
CBMNH
CDK
DHS
EBF
EED
FP
HIV
IPT
TT
ITN
KMC
MTCT
LAM
LMP
MMR
MTP
MICS
NMR
PMTCT
RHU
TA
TBA
Acceptable, Feasible, Affordable, Safe and Sustainable
Acquired Immunodeficiency Syndrome
Antenatal Clinic
Ante-partum Haemorrhage
Ante-retroviral
Ante-retroviral Virus
Community Based Maternal and Neonatal Health
Clean Delivery Kit
Demographic Health Survey
Expressed Breast Feeding
Expected Date of Delivery
Family Planning
Human Immunodeficiency Virus
Intermittent Preventive Treatment
Tetanus Toxoid
Insecticide Treated Nets
Kangaroo Mother Care
Mother to Child Transmission
lactitioneal Amenorrhea Method
Last Monthly Period
Maternal Mortality Rate
Medical Termination of Pregnancy
Multiple Indicator Cluster Survey
Neonatal Mortality Rate
Prevention from Mother to Child Transmission
Reproductive Health Unit
Traditional Authority
Traditional Birth Attendant
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FOREWORD
Malawi is currently implementing several programs aimed at meeting its health
policy. Despite these programs and the achievements made towards the
implementation of the policy, maternal and neonatal mobility and mortality still
remains high. To complement the health policy Malawi government adopted the
Millennium Development Goals derived from the Millennium Declaration in year
2000. The Millennium Goals that directly fall under the Ministry of Health are 4, 5
and 6, and these are aimed at reducing child mortality, improving maternal health
and combating HIV and AIDS, malaria and other diseases respectively.
One of the strategies to implement these goals is to strengthen support for
community-based maternal and neonatal care, through empowering individuals,
households and communities to take responsibility for their health. The reduction of
neonatal mortality and improvement of maternal health at the community level
can also be achieved through; the provision of essential information pertaining to
maternal and neonatal health and the strengthening of the role of communitybased health workers.
Research has shown that Community Health Workers such as Health Surveillance
Assistant (HAS) can contribute to reduction of maternal and neonatal deaths. This,
based on this research, is the rationale behind the development of this manual
whose purpose is to empower HSA with skills and knowledge necessary for the
provision of information, counseling and referral of mothers and neonates to a
health facility appropriately. The manual will also help HSA understand the fact
that postnatal period is the most dangerous period for both mothers and babies.
C.V. KANG’OMBE
SECRETARY FOR HEALTH
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ACKNOWLEDGEMENTS
This training manual in Community Based Maternal & Newborn Care (CBMNC) is
culmination of concerted efforts of many individuals.
The Ministry of Health through the Reproductive Health Unit (RHU) and Health
Education Unit would therefore like to sincerely express its gratitude and
appreciation to all individuals, partner agencies and collaborating institutions for
their support and valuable contributions during the process of developing this
manual.
We are also conveying our thankfulness to Monica Ogguttu, a regional consultant
who provided technical assistance to the first Training of trainers’ course and
made recommendable contributions to the training manual.
We are grateful to UNICEF for providing the financial and technical support, which
facilitated the development of this manual.
Special recognition and gratitude is extended to the following individuals for their
special involvement and contributions in the development of the manual.
Dr Luwei Pearson
Dr Joseph de Graft- Johnson
Mrs Fannie Kachale
Mrs Diana Khonje
Mr Kamkwamba
Mr Maseko
Mr Edwin Nkhono
Mrs Evelyn Chitsa Banda
Mr Kistone Mhango
Mrs Hilda Chapota
Mrs Ester Kainja
Mrs Manganga
Ms Joyce Mphaya
Mrs Grace Mlava
Mrs Evelyn Zimba
Mr. Reuben Ligowe
Mrs Maggie Kambalame
Mr Kumbukani Kuntiya
Mrs Anna Chinombo
Mrs Chrissy Phiri
Mr Henderson Lomosi
Mrs Norah Mgawi
Dr Abigail Kazembe
Mrs Jane Namasasu
Mrs Regina Msolomba
Mr. C. Matola Dauda
UNICEF- ESARO
ACCCESS/Baltimore
Reproductive Health Unit
Reproductive Health Unit
Health Education unit- MoH
Health Education Unit- MoH
PHC- MoH
Central East Zone
Ekwendeni Mission Hospital
Mai Mwana
Mwai Mwana
MoH-MCHSU
UNICEF
UNICEF
Save the Children
Save the Children
Save the Children
White Ribbon Alliance
ACCESS/ Malawi
Kamuzu College of Nursing
Dowa district Hospital
Malawi College Health Scienc
Kamuzu College of Nursiing
Consultant
Kamuzu College of Nursing
Thyolo District Hospital.
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Mr. Patrick W. Chirwa
Rumphi District hosiptal
Mrs Towera Ng’oma
Dowa district hospital
Ms. Doreen Nyasulu
Chitipa district Hospital
Mr. Donex Mwale
Nkhotakota district hospital
Mourine Nyembezi Mtambo
Machinga District Hospiatl
Mrs Prisca Masepuka
Reproductive Health Unit
Mr. Illack Caseby Banda
PHC Training Centre- Mponela
Mr Francis M. Amadu
Thyolo District Hospital
Mr. Hans R. Katengeza
Reproductive Health Unit
Ms. Dorothy Lazaro
UNFPA
Mr Suleman Malik
UNICEF
Mr. Chikondi Khangamwa
UNICEF
Mr. Dennis Chiombeza
Millenium Village- Zomba
Mr. Kelvin Nindi
UNICEF
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THE USER OF THE MANUAL
This manual has been developed to train Community-based health workers who
are already trained as Health Surveillance Assistants. A Health Surveillance
Assistant (HSA) is a Primary Health Care worker serving as a link between district
health services and the community. After undergoing the basic training a HSA is
capable of;

Motivating, informing and assisting individuals, families and communities in the
promotion and maintenance of personal and environmental health.

Detecting potential and real health hazards in the community and referring
them appropriately to a health facility.

Detecting and reporting disease outbreaks.

Working directly with village and community leaders; to identify and forming
community support groups; i.e. health committees, volunteers, and other local
service providers.

Collaborating with other extension workers; and Health Assistants,
Environmental Health Officers, Enrolled Community Health Nurse and Medical
Assistant within the Health Centre.
The aim of this manual is therefore to equip Health Surveillance Assistant with
knowledge, attitudes and skills in maternal and neonatal health care at the
community level in collaboration with other community -based workers and
facility-based health workers.
By the end of the CBMNC training Health Surveillance Assistant should be able to;

Mobilize communities for maternal and neonatal health activities

Communicate effectively with mothers and individuals in the provision of
maternal and neonatal health care
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Provide essential care for a pregnant woman
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Provide essential information necessary for care during labour, delivery and
immediately after the birth of the baby
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Provide essential care for women and new born babies during the first week
postpartum
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Manage records and supplies

Supervise other community-based health workers
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THE LAY OUT OF THE MANUAL
This manual has been developed following the objective, question and content
format. It has been divided into five units geared towards providing the participant
with knowledge and skills necessary for providing care to mothers and their
newborn babies. The units are very essential in the care of the neonates and
mothers before, during and after delivery.
Unit 1:
Unit 2:
Unit 3:
Unit 4:
Unit 5:
Introduction to maternal and neonatal health
Essential Care for Pregnant Women
Essential Information necessary for Care during Labour,
Delivery
and Immediately after the Birth of the Baby
Essential Care for Women and Neonates during the First Week
Postpartum
Management of Supplies, Record Keeping and Supervision
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A GUIDE TO THE USER
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This manual is a training manual; it should be used during training sessions with the
assistance of a trainer. It can however be used sparingly at the work place. Be
aware that “people may forget what they are told but will remember what they
do”, so when learning please;



ask questions
be involved in your learning
try to understand new information in relation to what you already know; how
do your new ideas change your old ideas?
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UNIT 1:
INTRODUCTION TO MATERNAL AND NEONATAL HEALTH
The purpose of this unit is to provide Health Surveillance Assistant (HAS) with
background information for the implementation of community maternal and
newborn health activities. The unit will also empower HSA with communication and
counselling knowledge and skills.
1. 1
BACKGROUND INFORMATION
Specific Objectives:
By the end of this unit the HSA should be able to;
1. Describe the Maternal and Neonatal Health situation in Malawi
2. Outline the key objectives and interventions to reduce high maternal and
neonatal mortality in Malawi
3. Explain the role of HSA in Maternal and Neonatal Health
4. Explain the process of mobilizing communities for Maternal and Neonatal
Health activities
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1. 1.1: SITUATION OF MATERNAL AND NEWBORN HEALTH IN MALAWI
Indicators
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Maternal mortality rate – 984/100,000 Live births( DHS 2004)
Maternal mortality rate – 807/100,000 Live births( MICS 2006)
Neonatal mortality rate – 27/1,000 Live births
Neonatal mortality rate – 31/1,000 Live births
16,000 neonates die every year
5,900 mothers die every year
16 mothers dying every day
Causes of deaths:
Direct causes of deaths of maternal deaths
 Sepsis
 Obstructed labour
 Ruptured uterus
 Obstetric haemorrhage (ante partum haemorrhage (APH)
and post partum haemorrhage( PPH)
 Eclampsia
 Complications of abortion
1.2.2. Indirect Causes of maternal deaths:
 Malaria
 Anaemia
 HIV and AIDS
1.2.3. Leading causes of deaths for neonates
 Sepsis
 Low birth weight
 Pre-maturity
 Asphyxia of the neonate
1.2.4. Contributing factors to deaths – the 4 delays
 Delay in deciding to seek care
 Delay in reaching a health facility
 Delay in receiving care at health facility
 Delay in identifying complications
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Gaps in maternal & neonatal
care
100%
Gap in coverage between poorest and least poor
75%
9%
PNC for nonfacility births
50%
25%
0%
92%
56%
57%
53%
82%
Antenatal care
(at least one
visit)
Skilled attendant
during childbirth
Postnatal care
within 2 days
Excl. BF
Immunisation
(DPT3)
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2. KEY OBJECTIVES AND INTERVENTIONS TO REDUCE HIGH MATERNAL AND
NEONATAL MORTALITY IN MALAWI
2.1.
Road Map Objectives to reduce maternal mortality rate (MMR) and
neonatal mortality rate (NMR)
Objective 1
To increase the availability, accessibility, utilization and quality of
skilled obstetric care during pregnancy, childbirth and postnatal
period at all levels of the health care delivery system.
Objective 2
To strengthen the capacity of Families, Communities, Civil Society
Organizations, Government and individuals improve Maternal and
Neonatal Health.
2.2.
Road Map Key interventions to reduce maternal mortality rate( MMR) and
neonatal mortality rate NMR
1 Improving the availability of, access to, and utilisation of quality Maternal
and Neonatal Health Care including family planning and PMTCT services
2 Strengthening human resources to provide quality skilled care
3 Strengthening the referral system
4 Strengthening national and district health planning and management of
Maternal and Neonatal Health care including FP services
5 Advocating for increased commitment and resources for maternal and
neonatal health care including FP services
6 Fostering of partnerships
7 Empowering communities to ensure continuum of care between the
household and health care facility
8 Strengthening services that address adolescents’ sexual and
reproductive health services
9 Strengthening monitoring and evaluation mechanisms for better decisionmaking and service delivery of Maternal and Neonatal Health services
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2.3 Overall Goal & Objectives of Reproductive Health Programme
Goal
To provide accessible, affordable and convenient comprehensive reproductive
health services to all women, men and young people in Malawi through informed
choice in order to enable them to attain their reproductive health goals and rights.
Programme Objectives
Reproductive Health Programmes has the following objectives:
 To provide safe maternal health care, quality family planning, adolescent
reproductive health services and prevention and management of unsafe
abortion
 To prevent and manage Sexually Transmitted Infections (STIs) including
HIV/AIDS
 To prevent and manage infertility
 To increase awareness on early detection and management of cervical,
breast and prostate cancers
 To reduce the levels of unwanted pregnancies in all women of reproductive
age
 To strengthen the monitoring and evaluation systems
 To discourage harmful RH practices
 To prevent and provide support to victims of victims of domestic and abuse
 To promote adequate development of responsible sexuality permitting
relations of equity and mutual respect between the genders and
contributing to improving the quality of life of individuals
 To ensure that women, men and young people have access to the
information, education, supplies and services needed to achieve good
health and exercise their reproductive rights and responsibilities
 To promote BCC and Family Life Education to men, women and young
people to utilize services
 To provide quality services that are integrated, gender, sensitive and
responsive to the needs of clients
3.
THE ROLE OF HSA IN MATERNAL AND NEONATAL HEALTHH SERVICE
PROVISION
The Health Surveillance Assistant is a key health worker in the provision of
Maternal and Neonatal care at the community level; as such the HSA plays
a very important role in the care of mothers and new born babies. While in
the community the HAS should;
1.
2.
Identify pregnant women in the community so that visits can be
targeted during pregnancy and early postpartum for the greatest
impact.
Make three antenatal visits to all pregnant women in the community
as follows:
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

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First Visit—as early in pregnancy as possible within the First Three
months of pregnancy
Second Visit—during the 4th – 6th month of pregnancy
Third Visit during 7th – 9th months
3. Make three postpartum visits at home for all mothers and babies,
regardless of place of delivery as follows:



First post natal home visit: Day 1 after delivery (Especially for home
deliver since those delivering at health facility will be in hospital)
Second postnatal visit: Day 3
Third Postnatal visit: Day 8
4. Identify problems in mother and newborn baby in order to manage them:
In Mother
 Vaginal bleeding
 Fever
 Foul vaginal discharge
In Newborn Baby
 Difficult breathing, chest in drawing
 Too hot or too cold
 Not feeding properly
 Difficult to wake up
 Red cord stump or with pus, and eyes filled with pus
5. Maintain all registers and records.
6. Maintain HSA kit and seek timely replacement or repair.
7. Work with the supervisor on the day of the visit to the community.
8. Organize and conduct group health education talks.
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4. THE PROCESS OF MOBILIZING COMMUNITIES FOR MATERNAL AND
NEONATAL HEALTH (MNH) ACTIVITIES
4.1.
Preparatory Phase

In order to effectively implement MNH activities in the community it
is important that the community be mobilized. The goal of
mobilization of the community is to ensure that every member of
the community has a fair opportunity to hear the key messages
and that there is sufficient time for discussions and decisions.
Prepare by;
1. Selecting a health issue and defining the community.
2. Putting together a community mobilization team.
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3. Gathering information about the health issue and the
community.
4. Identifying resources and constraints.
5. Developing a community mobilization plan.
6. Developing your team.
4.2.
Entering the Community

The traditional authority is the first person to contact in the
community. Do your homework before the meeting, anticipate
questions and have answers and information available. Be
prepared.

Do not promise things you cannot deliver. Always remember that
first impressions last longer.
Always prepare what you want to present to traditional authority
Explain the objective of the visit, nature of the problem to be
solved, magnitude of the problem, who is most affected and the
contributing factors
Discuss with the TA the importance of the traditional authority in
assisting to solve the problem and importance of community
involvement in MNH issues.
Propose possible ways you would like to work with the community
and ask for the TA’s approval and input.




KEY POINTS
 Some problems are beyond your control
 Be realistic about what you can accomplish
 You did not create the situation, but you can
give key messages and work for
improvement
Exercise 1
GROUP WORK AND DISCUSSION: COMMUNITY ACTIVITIES ON MNH
1 You will be divided into small groups
2 Discuss what the communities have been doing to save the lives of
mothers and the newborns in the community.
GROUP WORK 1(A)
INSTRUCTIONS



Write your key responses on a flip chart.
Let each group present in plenary and allow others to comment.
You will be allowed 15 minutes for this activity.
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Refer to the question in the box below
Questions for group work
1. How many women in this village have died due to pregnancy
and child birth?
2. How many babies have died before the age of one year?
3. What did the women and babies die from?
4. What kinds of MNH care are currently available in the
community?
5. What groups, organizations, facilities, and individuals are
currently offering this care?
6. What are the main reasons women and newborns do not
receive the care they need?
7. What are prevailing beliefs and attitudes and practices
associated with prenatal, labour/delivery, and postnatal care
for women and newborns at house hold level?
8. What resources exist in the community to improve MNH?
9. What obstacles exist in the community to improving MNH?
10. What has been done in the community in the past to improve
MNH?
GROUP WORK 1(B)
INSTRUCTIONS
 You will be divided into two groups again to discuss the questions provided
below, You will be allowed 10 minutes for the discussions:
 Present in plenary and comment whenever necessary. You have 10 minutes for
the presentation
QUESTIONS
1 What can be done to achieve greater community participation and
acceptance?
2 Who are you going to work with to achieve that?
3 How are you going to work with the groups?
4 Explain your role to the community and how you will support the
community e.g. conducting orientations of various groups, home visits.
GROUP WORK 1(C)
INSTRUCTIONS
 In this group exercise you will use the stories given in the box below for
discussion
 You will be allowed 15 minutes to do this exercise
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Why newborn care is important to the community
Story 1: A woman in one village named Sara was pregnant with her
second child. She was very happy. Her first child, a lovely boy, was
already four years old. Sara’s family was poor as others in their village, and
she was thin. She was not able to attend antenatal care regularly
because the nurse in the nearby health centre had left. When labour
started, Sara called the TBA. Although the TBA did what she could, when
the baby was born it was small and weak. Sara’s mother-in-law fed the
baby sugar water and very watery porridge. The baby got weaker and
weaker, became cold, and died after three days. Sara was very sad; she
blamed herself and became unhappy. The whole family suffered.
What should have been done to avoid this death?
This story is not uncommon. Do you know of a similar story from your
community?
Story 2: Florence went into labour and called the TBA. She had a long
labour and when the baby was born she started to bleed profusely. The
birth attendant tried to control the bleeding and referred the mother to
health centre. However, there was no readily available transport to take
the mother to the hospital which was 15Km away from the village. By the
time the transport was found, the woman became weak and by
eventually died on arrival at the health facility. Everyone in the family was
affected.
What contributed to the death of the woman?
What could have been done to prevent the death?
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1. 1: INTERPERSONAL COMMUNICATION
Specific Objectives
By the end of this unit the HSA should be able to;
1. Define communication
2. Discuss the three main components of interpersonal communication
3. Explain how health education aids can be used when talking to women and
or family members
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1.
DEFINITION OF COMMUNICATION
Communication is defined as;



Process of sending messages from source to receiver through channels;
e.g. from extension worker to family, community etc;
Involves coming up with messages that contain appropriate information
to be shared with an audience;
Process of creating shared meaning through messages, interaction and
getting feedback from an audience;
An effective communicator is somebody who;








2.
Listens
Speaks clearly so that others will understand
Confirms understanding asks others to do the same
Does not use jargon
Asks for questions and encourages others to speak
Is patient
Presents information in small amounts
Does not suppress others
THE MAIN COMMUNICATION COMPONENTS
The following are the main components of communication;
1. Building rapport and creating a caring environment.
2. Gathering information to establish plan of care required: questioning
and listening.
3. Counselling and sharing information: What parents need to do to care
for themselves or their children.
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2.1.







2.2.
Building Rapport
Greeting the mother
Making the woman feel relaxed by smiling at her and maintaining eye
contact
Using appropriate body language
Using soft tone,
Giving reasons for the visit,
Asking how mother and baby are,
Showing empathy
Gathering and Sharing Health Information and Counselling
Explore parent’s understanding of illness or situation to see what
they already know:
 This is important so that you can build on what they
already know instead of talking at them as if they didn’t
know anything.
 It can also identify any beliefs that may be harmful.
Correct, misconception of facts:
 Sometimes people believe things that can be harmful.
An example:
o Some people believe that children should not be fed
when they are sick; this is not true and can be harmful
to the child.
o Some people think illness is caused by an evil eye so
that they should go for spiritual healing from ‘a
medicine man’.
 Be sensitive when you correct misconceptions; do not
make the person feel stupid. Only correct
misconceptions that may have a harmful effect.
Explain the situation clearly; use simple, non-medical language:
 Always use simple, everyday words.
Explain what the mother (or father) needs to do—in short
sentences and clear blocks of information:
 Present the information clearly (think before you speak).
 An example of a ‘block’ of information would be:
 “Take 1 pill in the morning and 1 in the evening.”
 “Take the pills for 5 days” or
 “Eat more when you are pregnant”. “Try eating an extra
chapatti and more vegetables every day”.
Ask the mother to repeat what she needs to do in her own
words:
 This is very important to ensure that she understands
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what needs to be done including medicine if needed,
feeding advice, danger signs to look for, and when to
seek help.
Discuss the plan of care to encourage compliance:
 Ask for any questions.
Summarize and repeat key information:
 Repeat the main points.
Follow up if indicated:
 Mention when you will visit them or when they should
come to see you again.
 Review danger signs and when immediate care is
needed.
GROUP WORK 1(D)
Practising Interviewing a Client



3.
Each participant will be allowed interview at least 2-3 of the other
participants.
15 minutes will be allowed to practice the interviews.
At the end of the exercise, participants will be allowed to ask questions
and make comments.
HOW TO USE HEALTH EDUCATION AIDS WHEN TALKING TO WOMEN AND OR
FAMILY MEMBERS
Tips for Using Visual Aids




Only use relevant materials at each visit, that are specific to the client’s
needs.
Do not use too many visual aids at one time.
Hold cards (or any visual aid) so clients can see the illustrations clearly.
Ask the mother what she sees. Listen to her answers. It is important to
have her involved in the discussion.
“The goal is for the person to learn new information and to adopt healthful
behaviours. It is not about how much the HSA knows and can recite”.
 There should be a dialogue between the HSA and the mother; the HSA
should not do all the talking, but should also practise the art of listening.
 The counselling card: the back of the card is a reminder of the main
points; try not to read it but to discuss them with the mother.
 Point to the illustration if you are explaining it or clarifying a question.
After counselling and using the visual aid ask the mother or family member
to tell you what they understand and will try to do.
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KEY POINTS
 Active listeners are attentivethey communicate interests and
concern with their words and
body language
 Effective listeners summarisewhat they have heard and how
they understand what has been
said
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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QUESTION GRID
1.1
Closed
Questions
1.2 Openended
Questions
1.3 Probing
Questions
When detailed
information is
needed, about
symptoms,
feelings, etc.
When more
information is
needed.
Greeting,
history-taking
and during
counselling
History-taking and
Counselling
Longer reply;
allows for
expression of
feelings and
concerns
Explanation of an
earlier response or
statement
1.4. Lading
Questions
When to use:
When specific
response is
required.
Some questions
in history-taking
or in emergency
situations
Requires:
Brief and exact
response. Often
“yes” or ‘no”
answer.
Avoid using. Little
is learned from
them.
Person is
influenced by the
question
Examples:
How many
children do you
have?
Can you
describe the
pain to me?
Can you tell me
more about the
pain?
Don’t you think
you should deliver
in the hospital?
Why do you
believe that
colostrum is
harmful?
Are you
bleeding?
How do you feel
about that?
Fill in sample
sentences:
_
1.
1.
1.
1.
2.
2.
2.
2.
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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MODEL ROLE PLAY SCRIPT 1:
Interpersonal Communication Process and
Counselling for HIV
Part I – Building rapport and creating a caring environment
________________________________________________________________________________
HSA:
Mary:
HSA:
Hello Mary. (Smiles and makes eye contact) I’m glad to see you. I’ve
come for a visit to see how you are doing. How are you and the
family?
We’re okay.
I’m glad to hear this.
________________________________________________________________________________
Part II – Gathering information – questioning and listening
________________________________________________________________________________
HSA:
Mary:
HSA:
Mary:
HSA:
Mary:
HSA:
Mary:
HSA:
Mary:
HSA:
Mary:
HSA:
Mary:
How are you feeling?
I’m fine, a little tired but I have a lot to do around the house
I know, many women feel tired when pregnant because we have a
lot of work to do and our body is busy growing the baby.
(Acknowledging how she feels). Let me ask you if you went to the
health centre for antenatal care like we discussed last time?
Yes, I did. My husband took me a few weeks ago.
(Smiling) that’s really good Mary. What did they do there?
Like you said, they gave me the injection, took my blood pressure,
and gave me some iron and folic pills.
Very good. Are you taking the pills? (Closed-ended question)
Yes. I am.
Do you have any problems with the pills?
No. It’s okay
Good. Mary, remember our discussion about getting an HIV test to
protect you and the baby? Did you get the test taken?
Yes, I did.
That’s excellent. I’m sure the nurse at the clinic gave you the
information you need. If not, please know that I am available to talk
to. You do not have to tell me your test results, but if you do, I want to
assure you that I will not speak of it to anyone without your permission.
Thank you. As it happens, I do want to talk to you. The nurse said I was
negative but that my husband could be positive. He didn’t take the
test as he said it was a clinic for pregnant women. If he is positive,
then I could get HIV while pregnant. I am shy and a little afraid to ask
him to go for the test.
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_____________________________________________
Part III – Sharing Information about plan of care
_______________________________________________________________________________
HSA:
Mary:
HSA:
Mary:
HSA:
Mary. I’m very glad your test is negative, and I hear you saying that
you don’t want to ask him to go for the test but you know he should
(paraphrasing). I understand what you feel (reflecting feelings,
normalization).
Would it help if I came for a visit and talked to both of you? I will
explain that the test will give you information so that you can protect
yourselves, the baby and the family. Your husband can go for the test
on a day when pregnant women aren’t there.
If you are both negative you can learn how to prevent getting the
disease. If he is positive you can learn how to protect yourself and the
baby, and how he can get help. (giving information in a block)
Yes, that would be helpful. He will be home for lunch, could you come
today?
Yes, I’ll come just after lunch.
Thanks very much. See you later.
Okay. See you then. Good bye.
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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UNIT 2: ESSENTIAL CARE FOR A PREGNANT WOMAN
The purpose of this unit is to equip the H.S.A with knowledge, attitudes and skills to
enable them plan and conduct home visits for dissemination of key messages for
proper care and support of pregnant women.
Specific Objectives
By the end of the unit HSA should be able to:
1. Register all women of child bearing age (15-49) and all pregnant women
in the community
2. Define commonly used terms in Maternal and Neonatal Health (MNH)
3. Explain why antenatal care is important for health of mothers and unborn
babies
4. Determine LMP and EDD for the pregnant woman
5. Provide care during three targeted antenatal visits to all pregnant women in
the community
6. Provide key messages on HIV testing, counselling and care
7. Use ANC screening and counselling cards and referral notes
8. Conduct home visits
_____________________________________________________________________________
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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1. REGISTERING WOMEN OF CHILD BEARING AGE AND PREGNANT WOMEN
IN THE COMMUNITY

In order to care for pregnant women and newborns, the HSA should
know who is pregnant in the village. The first activity is to review the
Village Health Registers and identify all women of childbearing age and
list them on Women of Child bearing age form.

For HSA who do not have their Village Health Registers (VHR) ready, they
should visit every home, listing women of child bearing age and
complete this section of the VHR.

Complete women of child bearing age handout on page ----- and
answer all questions

If a woman is obviously pregnant, ask if she has an antenatal card. If yes,
check the pregnant column on the ‘Women of Child Bearing age’ form.
Then copy her name onto the ‘List of Pregnant Women’ form.

If a woman has missed her period, but has not been to the clinic, put a
check in the ‘pregnant’ column. Discuss with the woman on any sign of
pregnancy and refer the woman to ANC for pregnancy confirmation.
The HSA should revisit this woman within two weeks to get pregnancy
confirmation and conduct first ANC home visit counselling. Ask for any
questions and clarify any confusion.

You should revisit every household and update this form every two
months in order to identify pregnant women early enough so they can
attend ANC and receive at least 3 visits from the HSA.
After visiting all the households there will be 2 lists: the List of all Women of
childbearing age and the List of Pregnant Women.
Other approaches for identifying pregnant women include establishing
linkages with TBAs, women counsellors, set up mechanism where the
women can report to HSA privately.


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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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INTERPERSONAL COMMUNICATION SKILLS CHECKLIST
COMPONENTS
Creating a Caring Environment
Yes
No
Comment
Skill: Building Rapport
Greets the woman
Makes woman relaxed by smiling, eye contact, body
language
Uses soft tone, explains visit, asks how mother and
baby are, shows empathy
Gathering Information for Care Plan
Skill: Questioning and Listening
Using appropriate questions and listening actively








Encourages dialogue: open-ended questions
Shows that he/she is listening
(head nodding, eye contact, acknowledging
sounds, yes…hmm)
Does not interrupt
Seeks more information: probing questions
Avoids jumping in with premature diagnosis
Reflects feelings
Acknowledges (make client feel noticed and
normal)
Paraphrases what mother says
Counselling Effectively
Skill: Counseling and Sharing Information

Asks client’s understanding of illness or situation

Discusses and try to correct any misconception or
rumour

Uses simple and understandable language

Asks for any questions or concerns

Presents the care plan (what the client needs to
do) in short sentences and in clear blocks of
information

Uses visual aids when appropriate

Asks the client to repeat what she needs to do

Asks if she agrees and will try to do what is being
discussed

Summarizes and repeats key information

Arranges follow-up as indicated
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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HANDOUT 1 List of all women of child bearing age
No.
Village
household
code
Name of woman
Age
Pregnant
(Tick if yes)
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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HANDOUT 2 List of all pregnant women and home visits
Name of
woman
village
age
LMP
/
EDD
Date
1st
ANC
visit
Date
2nd
ANC
Visit
Date Date of
3rd
Delivery
ANC
Visit
Place of
Delivery
Outcome
Mother &
Baby
Date
1st
PNC
Visit
Date
2nd
PNC
Visit
Dat
e
3rd
PNC
Visit
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
29
MATERNAL AND NEONATAL HEALTH
________________________________________________________________________________
2. DEFINITIONS OF COMMONLY USED TERMS IN MATERNAL AND NEONATAL HALTH
Gestation: The duration of pregnancy. It is normally 280 days or 40 weeks
Abortion: If the baby dies before 6 months and 15 days of gestation. An
abortion can occur naturally (miscarriage) or it can be performed by a
medical person (Medical Termination of Pregnancy -MTP). Sometimes
unqualified people also perform abortions (this is dangerous).
 Stillbirth: Baby is born without breathing, crying or moving limbs (and is more
than 6 months and 15 days gestation).
 Live Births: Baby born after more than 6 months and 15 days gestation, and
shows any one of the signs of life at birth (even briefly): breath, cry,
movement of limbs.
 Premature Birth Baby born before 37 weeks
 Neonatal Death: If baby dies between birth and 28 days of life (and if the
gestation is more than 6 months and 15 days). Even if the baby only
breathes once and then dies, it is still a neonatal death.
 Maternal death: Death of the mother during pregnancy and within 6 weeks
of delivery or following an abortion
_______________________________________________________________________________


3. THE IMPORTANCE OF ANTENATAL CARE (ANC) TO MOTHERS AND UNBORN BABIES
Antenatal care is important because during this care mothers are screened,
counselled, given key messages to prevent illnesses and referred
appropriately for further care
.
3.1. Antenatal care can prevent illness to mothers and babies and improve
their health through the provision of the following:






Iron and folic tablets to prevent anaemia
At least 2 tetanus toxoid immunizations to prevent tetanus
Advice on nutritional requirements
Advice on importance of immediate breast feeding for contracting
mother’s uterus and exclusive breastfeeding for the newborn nutrition
Intermittent preventive treatment (IPT) and ITN
Provision of PMTCT and treatment for HIV infected mothers
3.2. During Antenatal care; problems can be identified and treated through;



Blood pressure checks: if elevated providing care advice and if
necessary treatment
Checking for maternal infections (syphilis, malaria, urine infection, STDs,
HIV etc)
Identification of danger signs during pregnancy and inform women and
families on when they need to seek care immediately
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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________________________________________________________________________________
3.3 Antenatal care can help families plan for the birth of the child

Completion of a birth plan (although mostly in this initiative Birth Plans will
be completed by HSAs)
KEY POINTS
Why women do not attend ANC
 Long distance to the health facility
 Poverty / high medical costs
 Cultural Beliefs
 Poor attitude of Health Care Worker
 Impassable roads
 Lack of knowledge on importance of
ANC
EXERCISE 2 (a)
Evaluation Ball Game (10 minutes)
________________________________________________________________________________
4. DETERMINING LMP AND EDD FOR THE PREGNANT WOMAN
This method gives an approximate date of delivery, and a baby can be born 15
days before or after.
EDD = LMP + 7 days + 9 months
Examples:
LMP: 10th Dec. 2003
EDD: 17th Sept.2004
th
LMP: 28 Sept. 2003
EDD: 5th July 2004
LMP: 2nd Nov. 2003
EDD: 9th August 2004
________________________________________________________________________________
If a woman has not had her period since her previous delivery, and she is again
pregnant, the HSA will not be able to determine the LMP or EDD.
________________________________________________________________________________
Example:
If LMP is 10 April 2007, what is the EDD?
Answer to Example:
Refer to the formula EDD= LMP + 7 days + 9 months
________________________________________________________________________________
If the woman doesn’t know her LMP the HSA can estimate the last LMP based on
certain festivals or agricultural landmarks (harvesting time etc)
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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________________________________________________________________________________
5.
CARE DURING THREE TARGETED ANTENATAL VISITS TO PREGNANT WOMEN IN
THE COMMUNITY
The visits should be scheduled at least two months apart and the last visit should at
least be 6 to 7 weeks before the EDD to ensure that there is enough time to
complete the Birth Plan and counsel the mother appropriately
5.1.
SCHEDULES OF VISITS

The first visit should be as soon as the pregnancy is confirmed (when the woman
misses at least 2-3 periods)

The 2nd visit should be between 4th to 6th month

Make a third visit during the 7th to 9th month of pregnancy
5.2.
ACTIVITIES CONDUCTED DURING EACH VISIT.
First Visit—as early in pregnancy as possible within the First Three months of
pregnancy





Encourage all pregnant women to go to the nearest health facility for
antenatal care (ANC) and provide information on importance of ANC.
Counsel the pregnant mothers that during ANC, the expectant mother will
have her blood pressure measured, will receive iron and folic acid
supplements, tetanus toxoid (TT) injections and intermittent preventive
treatment (IPT) for malaria; will get ITNs she may also have HIV testing and
advice on PMTCT (prevention of mother-to-child transmission), if indicated.
Counsel the women on minor elements of pregnancy management and or
care seeking. The minor elements include morning sickness, nausea and
vomiting, craving for food, heart burn, dizziness)
Counsel women on hygiene, rest and good nutrition
Provide health education (using Counselling Cards appropriately) on
danger signs in pregnancy
Second Visit—during the 4th – 6th month of pregnancy
The HSA should counsel the family on:


All of the above
Early recognition of danger signs during pregnancy and prompt care
seeking. The danger signs include : (Job aid on danger signs)
o A pregnant woman with heavy vaginal bleeding
o A pregnant woman with fever
o A pregnant woman with swollen hands and face
o A pregnant woman with severe headache
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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o A pregnant woman with fits
o A pregnant woman who is very pale and tired





Subsequent visits for ANC
Check on the ANC card to ensure that they received the care required
e.g. TTV, IPT, ITN, HIV testing
Conduct health screening for danger signs and refer if present. (Danger
Sign Sheet/Referral Note).
Assist family to develop a birth plan and needs for complication readiness
(Job aid)
Advise that the person who will be the birth companion should be
present
Third Visit during 7th – 9th months
The HAS should perform the following activities

Counsel the family on:
o Care seeking for skilled attendant at birth
o Clean and safe delivery
o Care of baby immediately after birth – asphyxia management,
wrapping, rubbing and drying the baby, delaying first bath
o Care of the mother and newborn at home
o Early initiation within the first hour and EBF for six months
o AFASS counselling for HSAs if the mother is HIV positive
o Newborn warmth, skin-to-skin, delaying first bath
o PMTCT
o Family planning – birth spacing for 3 years and LAM
o Common postnatal maternal and newborn danger signs which
include:
Baby
o Difficult breathing, chest in drawing, Too hot or too cold, Not
feeding properly, convulsions, Difficult to wake up, Red cord stump
or with pus, and pus filled eyes
Mother
o Heavy vaginal bleeding, Fever, Foul vaginal discharge, convulsions




Review and complete the birth plan – check if anything has changed
Check if mother has Clean Delivery Kit (CDK), If not give one. Discuss how
they can use the CDK if they deliver at home
Review danger signs in pregnancy and delivery and Check for presences
of danger signs using screening card
HSAs need to know the code for PMTCT and be able to deal with the
mothers.
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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 Encourage family to inform the HSA when labour starts and when they go
for delivery at Health facility or TBA
 Talk about post natal visits and need for PNC which will be conducted by
the HAS
 Encourage women living far away and where referral is difficult to use
waiting homes/ ANC waiting wards or live with relatives closer to health
facility
 Encourage HIV + women to deliver in a health facility that offers PMTCT
services. Ensure confidentiality.
 Recommend that someone be present to help the mother, during
delivery at health facility or home i.e. a birth companion (family member,
female HSA or TBA).
EXERCISE 2 (b)
TARGETING VISITS
INSTRUCTIONS



Divide the participants into groups of three to do the case study exercise
Allow 10 minutes for the exercise
After 10 minutes let the groups present in a plenary
CASE STUDIES:
(a)
You are visiting Naomi Jamali, it is mid- December and she has missed
several periods. Her LMP was 1st October. You assume she is pregnant.
When do you schedule the visits?
(b)
You are visiting Mrs Aida Banda at the beginning of March and you
find out that she is pregnant. She already has been to the clinic and
her antenatal card indicates that she is to have her baby on June 15th.
When do you schedule the home visits during pregnancy?
(c)
You are visiting Mrs Maria Bundu. It is May 30th and she has missed 5
periods. Her LMP was 20th December. When do you schedule the 2
home visits during pregnancy?
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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________________________________________________________________________________
Dzina: _______________________________
Tsiku loyembekezera kubadwa kwa
mwana:____/_____/_______
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
MATERNAL AND NEONATAL HEALTH
________________________________________________________________________________
Dzina: _______________________________
Tsiku lochira: ____/_____/_______
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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________________________________________________________________________________
MODEL ROLE PLAY SCRIPT 2: COMPLETING THE BIRTH PLAN
________________________________________________________________________________
Part I – Building rapport and creating a caring environment
________________________________________________________________________________
HSA:
Hello Kezia. (Greeting, smiles and makes eye contact) I’m glad to see
you. I’ve come for a visit as you are now 8 months pregnant. (Explains
reason for visit)
How are you and the family?
Kezia:
I’m feeling fine and I’m getting bigger! The family is fine too.
HSA:
OK (smiles shows caring).
________________________________________________________________________________
Part II – Gathering information – questioning and listening
________________________________________________________________________________
HSA:
One of the things I would like to do during this visit is to discuss your
birth. It is important to plan for the birth and to be prepared. Have
you heard about a Birth Plan? (close ended question)
Kezia:
Yes, my friend Bisa told me about it. She said it helped her and her
husband and gave her confidence.
HSA:
I’m glad you know that. (Nodding, shows you are listening) Is your
husband home? It is best to do it together
Kezia:
Yes, let me get him. (She returns with her husband Paul)
HSA:
Hello, nice to meet you.
Paul:
Hello.
HSA:
Shows them the Birth Plan. This is your Birth Plan. It will only take a few
minutes of your time, but it could save lives. Do you have a few
minutes to discuss it now?
Paul:
Yes, why not?
________________________________________________________________________________
Part III – Filling in the Birth Plan
________________________________________________________________________________
HSA:
Writes Kezia’s name and date of delivery on the front. Then opens it
up and points to the illustration of the health facility and the home.
What do you see in this picture? (open ended question – uses visual
aids appropriately)
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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Kezia:
Well, that is the health centre and that is a picture of a house.
HSA:
Yes, that is right. One of decisions you need to make is where you will
be delivering the baby. Have you thought about this? (asks for their
understanding of the situation)
Paul:
Not really, but everyone in our family usually delivers at home, and
mostly it has been OK
HSA:
Kezia, what do you think?
Kezia:
I agree with him – and also it is more comfortable to deliver at home.
HSA:
Yes, I understand what you are saying. (Acknowledging her feelings).
It is true it is comfortable at home, but sometimes problems arise
during the delivery, and it is safer to deliver in a place where these
problems can be taken care of or where they can refer you quickly.
(give information to correct misconceptions)
Kezia:
yes….perhaps it is a good idea. What do you think Paul?
Paul:
Sure, let us think about it…..
HSA:
Okay. Let’s go through each of these photos and decide how best to
cope
Paul:
OK
HSA:
Start with the first photo –points to it. (use visual aids appropriately)
This first one shows a woman being taken to the health centre. If you
were to deliver in the health centre, how would you get there?
Kezia:
That’s easy; there are frequent vans from our village
HSA:
Okay. HSA fills in the answer in the space provided. Then moves to the
next photo and points to it. Since you will be in labour that will go with
you? (eye contact, shows you are listening)
Paul:
I will. And if I’m not here then my sister will go with Kezia.
HSA:
Good. HSA fills in the answer and points to the third photo. Who will
stay with your children at home?
Kezia:
My mother-in-law. She lives with us. HSA writes that in and moves to
the next photo
HSA:
Okay. In this picture you can see a community health worker trying to
help in case of emergency. If you have any problems you can call me
and I can accompany you to the health centre. Doesn’t worry about
that (reassurance) HSA write her name in. Then moves to the 6th
photo. Is there money for extra expenses?
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
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________________________________________________________________________________
Paul:
We really don’t have a lot of money….but we could set aside a little
each week to have a little bit in case of emergency.
HSA:
Okay. Now the last photo: points to it. Do you have clean cloth,
clothes and nappies for the baby?
Kezia:
I can make some clothes and fix up some clean cloths and nappies.
There is enough time.
HSA:
Okay. Well, what do you think about the plan? (asking if they agree
to the plan)
Paul:
It is good. Going through all these questions shows that we can go
there and it’ll be safer for my wife and for my baby.
HSA:
It is a good decision that you have decided to deliver in the health
centre. (praise) But it is also important to review what you may need
in case you don’t get to the health centre and deliver at home. (Goes
through home birth needs….back page of birth plan…trained
attendant, hand washing, clean blade to cut cord, boiled cord ties,
dry and clean towels and clothes for baby.).
Kezia:
HSA:
Paul:
HSA:
HSA:
Paul:
HSA:
Now that we know what we need for the delivery let’s look at what
problems may arise; these are called danger signs. For the mother,
danger signs include heavy vaginal bleeding, high fever, severe
headaches or convulsions and the labour may take too long (uses
simple language). And in case of these problems you have to rush to
the health facility. Can you repeat them to me? (ask to repeat key
information)
Yes, vaginal bleeding, high fever, severe headaches or convulsions
and prolonged labour. (HSA nods and shows she is listening)
Very good. Once the baby is born, danger signs for the newborn
include, being too cold or too hot, not breastfeeding well, being too
sleepy or not able to arouse and not breathing well. Can you repeat
those for me? (ask to repeat key information)
Can I read them…too cold or too hot, not breastfeeding well,
difficulty breathing and too sleepy or not able to arouse. ? (HSA nods
and shows she is listening)
Very good. In case of these problems you will need to take the
mother and baby to the health centre, to get transport and you’ll
need extra money. You can always call me.
This is your Birth Plan. You should review and make sure you are getting
everything ready, and that you know the danger signs. (HSA
summarizes)
Thank you this is very helpful.
I will come and visit you. (HSA smiles, reassures, and plans follow-up
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6.
KEY MESSAGES ON HIV TESTING, COUNSELING AND CARE
_____________________________________________________________________
Your job is not to judge, but to provide care to all without regard to social status or
any other consideration
________________________________________________________________________________
HIV Testing and Counselling
It is recommended that all pregnant women and their partners be tested for HIV.
There are many benefits:
 If you are tested and you do not have HIV, you will learn how to protect
yourself and your baby from getting HIV
 Most women who are tested do not have HIV
 If you are tested and have HIV, you will learn how to lower the chance of
passing it to your baby and how to get treatment and care so you and your
baby can both live healthy lives
Not all women who have HIV will pass it to their babies. Without care 1 out of 3
women will pass HIV to her baby. This is why it is important to get tested for HIV and
receive medical care to lower the chance of passing HIV to your baby
Where and when:
 HIV testing may be conducted by a nurse or doctor trained in HIV testing during
an ANC clinic visit using a finger prick to get a sample of blood or it may
involve drawing blood from a vein in the arm.
 In all cases HIV test results will typically be available on the same day.
WHO definition:
Privacy: is the right and power to control the information (about
oneself) that others have.
Confidentiality: is the duty of those who receive private information not
to talk about it with others without the person’s consent. Confidentiality
is how the person’s right to privacy is protected.
All health workers must preserve confidentiality around HIV test results.
This means they should not tell other people or ‘gossip’.
People who receive an HIV test are encouraged to share their results
with their partners
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If a pregnant woman is positive
You can take steps to prevent mother to child transmission of HIV
You can take steps to promote, maintain or improve your health
You can get HIV care and treatment
You can take necessary steps to avoid getting additional HIV
infection (re-infection)
 You can take necessary steps to avoid infecting others
 You can take steps to ensure the best care for your child after
including keeping appointments immunization and health
appointments and giving all medications as explained at the health
facility
If a pregnant woman is negative





You can take steps to prevent getting infected with HIV (have your
partner tested and use condoms if he is positive, use condoms with
new partners, or decide not to have sex (this is called abstinence)
Prevention of Mother to Child Transmission (PMTCT):
PMTCT Antiretroviral (ARV) drugs can be given to the mother, and to her
infant, to protect the infant against HIV infection.
ARV prophylaxis
For the mother:
Content
Box is5:to be taken by the mother in pregnancy and/or during labour
 ARV

All women are encouraged to deliver at a health facility where
additional support can be provided;
For the infant:

One single dose of Neverapine suspension (2mg/kg) or 0.6mls for a 3 kg
newborn is given after birth, and no later than 72 hours after birth as a
one time dose

The best way to ensure that all infants of infected women receive NVP
is to make sure they are delivered at a health facility, or are taken to a
health facility as soon as possible after birth.
Note:
For ARV and PMTCT to work well, both the mother and her infant must take
their ARV medications as prescribed, on time, and for the full duration
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Delivery Care
 It is recommended that all women deliver in a health facility. Health workers
should wear gloves, and avoid contact with mother’s blood. Avoid
unnecessary vaginal examinations, prolonged labour, episiotomies and
other unnecessary trauma. Clean the baby off blood and secretions.
Follow up Post Natal
Post natal care for the HIV infected mother and infant is particularly important:


Infant feeding:
o Breastfeeding: Exclusive breastfeeding is necessary to prevent illness.
Breastfeeding mothers must be supported in breast care: good
positioning prevents cracking (a risk factor which can lead to infection
and a greater risk of passing the HIV to the baby). Feeding on demand
and frequently will keep breasts soft.
Formula feeding: Support must be given to ensure the use of clean water
and the correct amount of formula powder.

Family Planning: information, counselling and services
o Condoms are particularly encouraged either as the sole or additional
means of family planning, because in addition to preventing pregnancy,
they protect against HIV re-infection, as well as HIV transmission to sexual
partners

Counselling of partner and family if required
KEY POINTS
Stress the importance of family
planning for all women. Family
planning reduces;



The chance of becoming pregnant
and therefore the risk of a mother
dying in childbirth
The chance of passing HIV to a
child
The risk of a newborn dying after
spacing for at least 3 years
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7. USE OF COUSELLING AND SCREENING CARDS DURING THE THREE ANTENATAL
HOME VISITS.
Card
Card 1: Antenatal Check Up and care
Card 2: Nutrition
Card 3: Danger Signs during Pregnancy
Card 4: HIV and PMTCT
Card 5: Birth plan
Card 6: Safe delivery and immediate newborn care
Card 7: Breast feeding
Card 5: Birth plan
Card 6: Safe delivery and immediate newborn care
Card 7: Breast feeding
Card 8: Danger signs during delivery
Card 9: Family planning
Schedule
First home visit
during
pregnancy
Card
Card 10a): Common maternal danger signs
Card 10b): Common newborn danger signs
Card 11: Kangaroo Mother Care
Card 12: On going care of babies
Card 13: On going care of mothers
Schedule
First home visit
after giving
birth
Second home
visit after giving
birth
Third home visit
after giving
birth
Card 12: On going care of babies
Card 13: On going care of mothers
Second home
visit during
pregnancy
Third home visit
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MODEL ROLE PLAY SCRIPT 3: Using counselling cards during pregnancy
ROLE PLAY CARDS 1 AND 2
________________________________________________________________________________
Part I – Building rapport and creating a caring environment
________________________________________________________________________________
This role part takes place during the1st visit of pregnancy
HSA:
Mara
HSA:
Mara
HSA:
Hello Mara. How are you? I can see you are growing (Greeting, smiles
and makes eye contact)
I’m fine
I’ve come to visit you since you are pregnant and that is now part of
the work I do (explaining reason for visit)
You are welcome.
(smiles show caring).
________________________________________________________________________________
Part II – Gathering information – questioning and listening
________________________________________________________________________________
HSA:
Mara:
HSA:
Mara, have you been to the clinic yet?
Not yet, it is still early
Yes, but it is best to start early. Let me show you this card (brings out
Card 1 on Antenatal care)
CARD 1
What do you see in this card? (open ended question – uses visual aids
appropriately)
Mara:
Let’s see… a pregnant woman is at the health centre talking to a
nurse. Here she is getting an injection….and here she is taking some
pills.
HSA:
Yes, that’s right. Good. (Praise and encouragement)
Mara:
But I don’t understand why she is getting an injection?
HSA:
The injection is to protect the mother and child from tetanus, (use
local word) which can kill. It is very important that a pregnant mother
gets at least 2 shots during pregnancy. And these pills are iron and
folic to strengthen the blood
Mara:
Really okay. I remember my sister took those pills and got very
nauseous (HSA uses eye contact, to show she is listening)
HSA:
That is a very normal reaction. (acknowledging, making it seem
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normal) It is best to take the pills with meals and with citrus or
lemonade. If you have any problems with the tablets you can always
call me and we can discuss it further.
________________________________________________________________________________
Part III – Counselling and giving information
________________________________________________________________________________
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara
If you start these check ups early the doctor or nurse can take care of
any other problems and they will take care of it. It is advised to get at
least 4 check-ups during pregnancy.
Oh, I didn’t know it was so important.
Yes, it is very important. Mara, do women in your family go for checkups during pregnancy? (Ask her understanding of situation and what
she has done)
Most of them go. I went one or two times with my last pregnancy. But
now I know it is important.
Yes very, very important. So now that you are pregnant again what
will you do? (Ask what she will do (does she follow the plan)
I will definitely go for antenatal care….I will start this week.
That is really good. (Praise)
Mara, let me ask you a question….have you had an HIV test?
No, not yet
Why not? (Open ended question)
I’m afraid that if I am positive the other women will not talk to me
I understand how you are feeling; there are many women in the same
situation as you. (Acknowledging her feelings) But don’t be afraid.
Our government is asking everyone to come out openly and talk
about this disease. (Body language shows caring) But if you go for this
test the doctor will be able to take care of both you and the baby. Do
you know that the virus can be passed from you to the baby during
pregnancy and delivery?
Really?
Yes. So when you go for the test and if you are positive, they can give
you drugs to protect the baby and treat you and also give you
advice. So you see it is very important
I will ask my husband to go for the test this week
That is excellent Mara! (Encouragement)I will be visiting you in the
next two months to see how you are doing (advises on next visit)
You can come as many times as you want. Go well
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CARD 2
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
Mara:
HSA:
(pulls out Card No 2) Danger signs during pregnancy). What do you
see in this card? (Open ended question, uses visual aids well)
There are pictures of pregnant women, but they are not well…this one
is bleeding and this one looks like she is in pain…
Yes. What else?
This one has swollen hands and this one is pale and tired.
Very good. What do you think the message is?
I’m not sure. Maybe they are all sick?
Yes. Each picture shows a different problem or danger sign that can
occur to women during pregnancy. (Points to each picture) This shows
bleeding during pregnancy, this one a severe headache, this one
swollen hands and face, this one pale skin and tiredness, this one high
fever (name them all).)What should you do if you are sick?
Go to the medicine man?
Well, you could do that, (discuss any misconception or rumour) but if a
pregnant woman has any one of these danger signs it means she and
the baby could be in serious trouble, and need medical attention. It is
best to go immediately to the health centre
Oh, I didn’t know they were so serious.
Yes they are. Can you tell me – and you can look at the pictures
again – what the main danger signs are? (Ask to repeat information)
Yes, this one is bleeding, this is headache, this very pale and tired, this
swollen hands and face…..and fever
Very good. (Praise) Now if you had any of these, what would you do?
(Ask what she will do)
Now I know to go immediately to the health centre.
Yes. It could save your life and your baby’s. Do you have any
questions??(Asks for questions)
No, but I learned a lot. I will go to the antenatal clinic to register and
get care.
Good. I will come back to visit you again - about 2 months before
your delivery. If you need me before that, have someone send for me,
and I’ll come.
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ROLE PLAY SCRIPT 4:
HSA:
Mara:
HSA:
Mara:
HSA:
CARD 4: HIV AND PMTCT (2nd visit pregnancy visit)
Mara, hello, how are you?
I’m fine thanks. I went to the clinic for ANC as you suggested.
That’s good Mara. Did you also have the HIV test?
Yes I did.
I’m glad. Do you feel that you received enough information and
counselling at the clinic? If not, I may be able to help you. Please be
assured that I will protect your privacy and keep what you tell me to
myself (confidentiality).
Well the nurse did talk to me but it would help me if I could talk to you
too…I have a lot of questions.
I’ll be happy to help if I can.
The nurse told me I was HIV positive. I am very upset. My husband
was tested too and he is positive as well.
Mara, I am sorry to hear that, but now that you know the results, you
can protect your baby from contracting the virus by getting
neverapine from the health facility for you to get before delivery and
the baby after delivery.
Mara:
HSA:
Mara:
HSA:
8. CONDUCTING HOME VISITS
8.1.
Preparation for home visiting





8.2.
Know the client you are going to visit
Prepare objectives for the visit
Prepare materials (counselling and screening cards) and content for the
visit
Agree with the family about the visit
Agree with community on how the HSA will visit the family (for male HAS,
a third person is a must)
Visit Pregnant Women in the Community
KEY POINTS
When visiting homes remember to;






Be at the level of the people
Dress appropriately
Use language people can understand (do not
use intimidating language)
Always show respect to the family
Keep all information about the family confidential
Make sure the husband is included in the
discussion
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Pregnant Mother’s Form: Information of Mother
1.4
2
Part 1
1) Date of filling in the form
years)
2) Age of mother (full
3) Mother’s full name
4) Place of usual residence of mother
5) LMP
6) EDD
Date
Date
Month
Month
Year
Year
Part 2
7) Screening during present pregnancy: use screening card for problems during
pregnancy
Date
Danger sign if present
Action taken
Visit 1
Visit 2
Visit 3
8 b)
Ask how many times a mother eats in the day. 1time, 2 times, 3 times, 4
times? Encourage her to eat more during pregnancy.
9)
How many Antenatal Check-ups did you have?
01234
More If yes, in which months?
123456789
10a) In which month(s) of pregnancy did you receive iron folic? 1 2 3 4 5 6 7 8 9
did not get
10b) In which month of pregnancy did you take iron folic?
123456789
did not take
11) How many TT injections during pregnancy? One Two
Three did not
have
12) Birth Plan completed?
Yes
No
13) List counselling cards used
Visit 1:
Visit 2:
14) Any special information
HSAName:____________________________Signature:________________________________
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For Supervisor
Form was checked: Name
Date
Corrections
Any different information
Is the form complete during each visit?
Yes
No
Signature
Supervisor
EXERCISES 3:
CASE STUDY
CASE I
First visit: You are visiting Mrs Diana Bengo. Her LMP was June 1, her EDD
March 8. She is 4 months pregnant. She has not yet been to ANC. She
has no danger signs.
Second visit: Mrs Diana Bengo is attending ANC. She is taking iron and
has had 1 TT shot. She complained of burning on urination
CASE II
First visit: You are visiting Mrs Jane Nsapato. It is her first baby. Her LMP was
Dec 15. Her EDD is ___?
She is now 5 months pregnant. She has already registered for ANC.
When is the 2nd visit?
Second visit: Mrs Jane Nsapato has stopped going to ANC. She has no
danger signs.
CASE III
First visit: Mrs Naomi Banda has missed 4 periods. LMP October 10
Her EDD is ___? She has 5 children at home.
When is the second visit?
Second visit: Mrs Naomi Banda has had 3 ANC visits. She has no danger
signs and is feeling fine.
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UNIT 3: ESSENTIAL INFORMATION NECESSARY FOR CARE DURING LABOUR, DELIVERY
AND IMMEDIATELY AFTER BIRTH
The purpose of this unit is to equip the HSA with knowledge and skills to provide
information to mothers and families on danger signs during labour, delivery and
immediately after birth.
________________________________________________________________________________
SUB-UNIT 3.1 DURING LABOUR AND DELIVERY
Specific Objectives
1.
2.
3.
4.
5.
By the end of this sub-unit the HSA should be able to:
Explain the signs and symptoms of labour.
Explain danger signs in labour and childbirth
Discuss the disadvantages of home delivery
Mention the four delays contributing to maternal and neonatal deaths in
Malawian communities
6. Explain importance of Clean Delivery Kit (CDK)
________________________________________________________________________________
1. SIGNS AND SYMPTOMS OF LABOUR
At the onset of labour muscles in the womb tighten and pull open the mouth of
the womb causing pain as follows:
Pains are irregular at the beginning but become more regular.
Pains start from the back of the lower abdomen and move to the front.
Pains become more frequent, lasting longer and are stronger.
A sticky jelly mixed with blood flows out of the vagina and this is called ‘Show’.
______________________________________________________________________________
The first part of labour usually lasts about 8 to 12 hours. It may take longer if the
woman is having her first baby
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2
DANGER SIGNS DURING LABOUR AND DELIVERY
2.1
Bleeding:
Any bleeding before delivery and heavy bleeding after the baby is born, means
the woman needs emergency care immediately.
The woman can be informed to do the following while waiting for transport or in
transit to the health facility if the baby is already born:
Put the baby to the breast. It assists the womb to contract
Have the mother urinate; sometimes a full bladder can affect the womb from
clamping down and results in bleeding
Place a hand on the mothers abdomen, one hand on the top to the womb and
one on the bottom (above the pubic bone) and massage to get the womb hard
2.2
Fits or convulsions
2.3
Prolonged labour- lasting more than 8 hours requires immediate referral to
the health facility.
2.4
Retained Placenta-i.e. Placenta is retained if it does not come out within 30
minutes after the delivery of the baby
2.5
Baby’s hand, foot or umbilical cord comes before the head
________________________________________________________________________________
Most complications are unpredictable but preventable.
All pregnant women are at risk of developing a complication during pregnancy or
child birth. The rate is estimated at 15%
_______________________________________________________________________________
DISADVANTAGES OF HOME DELIVERY
The HSA should inform the women and family members to seek for skilled delivery
at all times.




Disadvantages of home delivery:
Non availability of skilled attendant to make proper judgment and institute
immediate care to both mother and baby.
Non availability of life saving drugs and equipment.
Too far for referral to a health facility incase of emergency.
Cleanliness of home environment is un- predictable.
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3.2. Some issues that need emphasis
The risks of maternal death are:
To become pregnant
To develop a complication before, during and after delivery
________________________________________________________________________________
4. DELAYS CONTRIBUTING TO MATERNAL AND NEONATAL DEATHS IN MALAWIAN
COMMUNITIES
There are several delays that can contribute to maternal and neonatal death.
The following are the four major ones:




Delay in deciding to seek care.
Delay in reaching an adequate health facility.
Delay in receiving adequate treatment at that health facility
Delay in identifying complications
5. IMPORTANCE OF CLEAN DELIVERY KIT (CDK)
A clean delivery kit contains materials that are in a sealed transparent plastic
bag to maintain cleanliness. The use of this delivery kit minimizes the
introduction of infectious agents to the mother and baby which may lead to
sepsis
The clean delivery kit contains the following:
1. Soap
2. Blade
3. Cord ties
4. Gloves
5. Plastic delivery sheet-Black paper
6. Pictorial insert
7. Candle/matches
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SUB-UNIT 3.2 IMMEDIATE CARE OF THE BABY IMMEDIATELY AFTER BIRTH
1. Specific Objectives
2. By the end of this sub-unit HSA should be able to:
3. Explain the immediate care of the newborn
4. Explain the importance of keeping the baby warm
5. Demonstrate how to use a digital thermometer and count respirations in a
newborn
6. Explain the danger signs in the newborn
1.
IMMEDIATE CARE OF THE NEWBORN
The immediate care of the newborn includes the following:





3.
Drying the new born baby immediately after birth
Checking for breathing immediately after birth
Placing the baby skin to skin on mother’s belly and cover with dry towel
Cutting and tying the cord immediately after birth
Starting breastfeeding within 30 minutes after birth
IMPORTANCE OF KEEPING THE BABY WARM
Babies have difficulties in maintaining their temperature at birth and in the first few
days of life unlike an adult or older child. If the baby is not properly dried,
wrapped with her head covered, then the newborn is not protected from heat
loss; can lose 2-4 degrees in 10-20 minutes.
Picture 1: WAYS OF LOSING HEAT IN THE NEWBORN
Source: WHO 1997: Thermal Protection of the Newborn. WHO/RHT/MSM/97.2 Geneva
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It is therefore very important to keep the baby warm because:
If the babies get cold, they use up a lot of energy and can become sick.




Low birth weight and premature babies are at greater risk of getting cold
Most newborns lose heat in the first few minutes after delivery. The babies
are born wet and if left wet and naked, they lose a lot of heat into the
air.
A newborn baby’s skin is very thin and its head is big in size compared to
its body as such a baby loses heat very quickly from its head.
Babies do not have the capacity to keep themselves warm.
If the babies’ temperature is below normal they suffer from hypothermia


A baby who is cold, and has a low temperature (hypothermia) has
decreased ability to suckle the breast leading to poor feeding and
weakness.
The baby feeds less and the amount of glucose or sugar in the blood
decreases. This affects the baby’s brain and further increases risk of:
o Infection.
o Death especially in low birth weight and preterm babies
KEY POINTS
Early signs of hypothermia
are;
 First, the feet are
cold
 Then the whole
body becomes cold
2.2.

Main points on keeping the baby warm
Skin to skin:
o Putting the baby and mother skin to skin helps to warm the baby,
and stimulates the baby’s interest in feeding. It also develops the
bond between mother and baby.
o If skin to skin is not possible, wrap the baby after being dried and
place him/her in the mother’s arms. The baby can be clothed later
o Uncover the baby as little as possible.
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


Initiating breastfeeding as soon as possible.
o This ensures a good milk supply and helps the baby maintain its
temperature.
o The nutrients in colostrum provide energy the baby uses to
generate body heat.
Putting a hat on the baby
o This saves a lot of heat loss through the baby’s head.
o Wrapping baby in dry soft clothes.
o Avoid overheating the baby
Delay in bathing the baby for the first 24 hours of life:
o The whitish covering on the baby’s skin is harmless and should not
be wiped off.
Keeping baby warm through skin to skin
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UNIT 4: ESSENTIAL CARE FOR WOMEN AND NEWBORNS DURING THE FIRST WEEK
POSTPARTUM
The purpose of this unit is to equip HSA with Knowledge and skills to enable them
provide essential care to women and newborns during the first week of
postpartum period.
4.1 TEMPERATURE AND RESPIRATIONS
Specific Objectives
By the end of this sub-unit the HSA should be able to:
1 Describe how to check baby’s body temperature.
2 Demonstrate how to use a digital thermometer correctly to determine a
newborn’s temperature
3 Describe how to count respirations of a newborn
4 Demonstrate how to count respiration of a newborn
________________________________________________________________________________
1.
CHECKING BABY’S BODY TEMPERATURE
There are two ways that can be used to check the baby’s body temperature:
 By touch - the feet or the whole body may feel cold or hot
 By using a thermometer:
o Normal temperature is within the range of 36.5 to 37.4 degrees Celsius
o High is above 37.4
o Low is below 36.5
2.
STEPS TO FOLLOW WHEN USING A DIGITAL THERMOMETER TO CHECK
TEMPERATURE
Procedure of checking temperature
________________________________________________________________________________
Checking temperature using a thermometer is the most important and precise
way of confirming whether the baby’s temperature is raised or not
________________________________________________________________________________
1
2
3
4
Explain to the mother about the procedure
Assembly the items i.e. thermometer in its box, cotton and spirit
Wash hands
Take thermometer out of box, hold at broad end and clean the shining tip
with cotton and spirit.
5 Press the ‘on’ button once to turn the thermometer on. You will see “x x x”
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flash in the centre of the display window, then you will see ‘Lo’.
6 Hold the thermometer upward and place the shining tip in the centre of the
armpit.
7 Place arm against it.
8 Do not change the position.
9 Remove the thermometer when you hear 3 short beeps, and the numbers
on the display window are static, (this will take a few minutes).
10 Read the number on the display window.
11 Then record the temperature reading on the form.
12 Turn the thermometer off by pushing the “on” button once.
13 Clean the shining tip of the thermometer with cotton soaked in spirit.
14 Place thermometer in storage case.
15 Give the mother feedback.
_____________________________________________________________________________
Failure to perform this procedure correctly may lead to missing a danger sign of
fever in a baby
_____________________________________________________________________________
TAKING TEMPERATURE: SKILLS CHECKLIST
STEPS OF THE PROCEDURE
NOT
DONE
POORLY
DONE
PROPERLY
DONE
COMMENTS
1.Explains the procedure to the
mother
2. Washes hands
3. Cleans the thermometer
4. Turns the thermometer on.
5. Places the thermometer under
the armpit.
6. Removes the thermometer.
7. Reads the temperature
8. Records the temperature
reading on the form.
9. Turns the thermometer off
10.Cleans the thermometer
11. Stores thermometer.
12. Gives feedback to the mother
________________________________________________________________________________
3.
COUNTING RESPIRATIONS
When counting respirations in a newborn you must make sure that the baby is
calm, then;

Assess the breathing
o Look at the chest for in drawing
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o Look at the chest movements; if they are normal and symmetrical?


o Listen for grunting
Count breaths by exposing the chest only (do not over expose the baby)
Count breaths for one full minute.
o For a newborn baby 30-60 breaths per minute are normal
o If elevated repeat the count to confirm the elevation
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SUB-UNIT 4.2 BREAST FEDING
Specific Objectives:
By the end of this sub-unit the HSA will be able to:
1.
2.
3.
4.
5.
6.
Explain the anatomy of the breast
Explain how breast milk is produced.
Discuss proper breast feeding
List the advantages of early and exclusive breastfeeding
Outline factors that may affect breast feeding
Describe the most common problems associated with breastfeeding and
their management
7. Describe appropriate newborn feeding options for HIV positive mothers
_____________________________________________________________________________
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1.
ANATOMY AND PHYSIOLOGY OF THE BREAST.
Nipple
Areola
Gland
Duct
Supporting Tissue
Anatomy of the breast
The breast is made up of supporting tissue, gland tissue and fat.
Gland tissue (also called alveoli) makes the milk.
Milk ducts carry the milk to the sinuses for storage.
Milk reservoirs (or lactiferous sinuses) are wider than milk ducts and collect the milk.
Milk leaves the sinuses and enters the nipple through 10-20 fine ducts.
The nipple is the tip of the breast where the milk comes out.
The areola is the darkened areas around the nipple. The milk reservoirs are under
the areola (in a circle around the nipple).
Supporting tissue or breast tissue; supports the gland tissue, the ducts and the
sinuses.
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2.
HOW BREAST MILK IS PRODUCED
Anatomy of the breast
The breast is made up of supporting tissue, gland tissue and fat.
Gland tissue (also called alveoli) makes the milk.
Milk ducts carry the milk to the sinuses for storage.
Milk reservoirs (or lactiferous sinuses) are wider than milk ducts and
collect the milk.
Milk leaves the sinuses and enters the nipple through 10-20 fine ducts.
The nipple is the tip of the breast where the milk comes out.
The areola is the darkened areas around the nipple. The milk
reservoirs are under the areola (in a circle around the nipple).
Supporting tissue or breast tissue ‘supports’ the gland tissue, the ducts
and the sinuses.
How milk is produced (Refer to illustrations in CHW Manual)
Toward the end of pregnancy the body is getting ready to feed the
newborn. The breasts get bigger so that milk can be produced. Milk
is produced when the gland tissue in the breast is stimulated. Before
delivery a signal is sent from the mother’s brain to the gland cells to
‘make milk’. The signal to ‘make milk’ is carried by a hormone called
prolactin. This is why the first milk, called colostrum, is present at the
time of birth.
When the baby suckles at the breast, nerve endings in the breast are
stimulated. These nerves go to the mother’s brain and stimulate the
release of two hormones. One hormone is oxytocin, which squeezes
the milk from the gland cells into the ducts and to the milk reservoir
where it is stored. It also contracts the uterus which is why some
women feel a tightening when they breastfeed; this helps limit blood
loss. How a mother feels can affect the flow of oxytocin (if she is
tense, she may have difficulty with milk flow). When the milk is in the
reservoirs (also called lactiferous sinuses), the baby compresses the
areola with its upper mouth (palate) and tongue, squeezing the milk
reservoirs and causing the milk to flow out the nipple into the baby’s
mouth.
The other hormone produced when the baby suckles is prolactin,
which tells the gland tissue to make more milk for the next feed.
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3.
PROPER BREAST FEEDING
3.1 Beast feeding recommendations:
1) Start breastfeeding as soon after delivery as possible; within one hour.
2) Breastfeed on demand; when the baby wants but do not wait for
more than 4hours; for LBW babies feed every two hours.
3) Exclusively breastfeed for six months.
4) At six months continue to breastfeed and start adding other foods.
5) Continue breastfeeding at least two years.
3.2

Positioning
Different Breast Feeding Positions
Front hold or cradle position
Twins hold
Underarm position
Lying down
Breastfeeding in public
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
Signs for proper positioning and attachment
Proper positioning
 Mother relaxed and
comfortable
 Baby’s body close, facing the
breast to be suckled
 Baby’s head and body
straight
 Baby’s chin touching the
breast
 Baby’s bottom supported

Proper attachment
 Mouth wide open
 Lower lip turned outwards
 Tongue cupped around
breast
 Cheeks round
 More areola seen above
baby’s mouth than below
 Slow deep sucks, bursts with
pauses
 Can see or hear swallowing
Poor Attachment
Results of Poor Attachment

Pain and damage to nipples
(breaks in skin)

Breast milk not removed effectively
too full)

Apparent poor milk supply
feed a lot
Sore nipples and fissures
Engorgement (breasts
Baby unsatisfied, wants to
Baby frustrated, refuses to
suckle

Breasts make less milk
Baby fails to gain weight
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Inside and Outside Illustrations of Latch-on
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3.3
Burping


3.4
Importance of burping
o The air that is swallowed during breast feeding is expelled out
o Failure to expel the air may cause vomiting or regurgitation
How to burp
o After each breast feeding, place the baby up right to release the air
through the mouth
o Or place the upright against mother’s shoulder and rub the baby’s back
until the air is released
Breast Feeding Observation Tips
Signs of good breastfeeding








Mother’s body relaxed,
comfortable and confident.
Maintains eye contact with the
baby,
Touching the baby.
Baby’s mouth widely opened
well attached to the breast,
covering most of the areola and
the lower lip turned outwards
Baby calm and alert at breast,
stays attached to the breast.
Mother may feel uterus
cramping.
Some milk may be leaking
(Showing milk is flowing).
After feed, breasts soft, nipples
protruding.
Signs of possible breast feeding
difficulties
 Mother tense, leans over baby.
 Not much eye contact or
touching









Mouth not opened wide, not
covering the areola.
Lips around the nipple
Rapid sucks cheeks tense or
sucked in.
Smacking or clicking sounds
Baby restless or crying, slips off
breast.
Mother not feeling cramping.
No leaking (milk not flowing).
After feed, breasts full or
engorged
Nipples may be red, cracked,
flat or inverted.
KEY POINTS
1. The baby’s suckling is what controls the amount of milk produced,
so if the baby suckles more, more milk is made.
2. The baby gets the milk out by compressing the areola; not by
sucking on the nipple alone which will only make the nipples sore.
3. The baby’s suckling makes the uterus contract (less blood loss) and
temporarily stops ovulation meaning another pregnancy is delayed.
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4.
ADVANTAGES OF EARLY AND EXCLUSIVE BREASTFEEDING
4.1
Advantages of breastfeeding
Breast milk
 Perfect nutrients for the
baby
 Easily digested and used
 Protects against infection
 Prevents irritation of the
baby’s gut
4.2
Breastfeeding
 Helps bonding between mother
and baby
 Helps infant develop properly
 Delays a new pregnancy
 Protects mother’s health (less
blood loss)
 Costs less than artificial feeding
Exclusive Breastfeeding:

WHO Definition
o Breastfeeding the baby and giving no other food or drink (including
water) in addition to breastfeeding (except medicines and vitamin
drops).
o WHO recommends exclusive breastfeeding for six months.
o At six months the baby’s energy needs increase. Therefore breastfeeding
should be continued, and complementary food (along with
breastfeeding) should be started. Breastfeeding should continue for two
years

Advantages:
o Breast milk is completely clean; breastfed babies have much less
diarrhoea than babies not breastfed or those given other fluids or foods
even if also breastfeeding.
o Breast milk provides antibodies to fight infections. Babies exclusively
breastfed have fewer infections and if they get one, can fight it better.
o With exclusive breastfeeding, the baby regulates the amount of milk
he/she needs, and so the amount produced equals what is needed. This
happens because when the baby suckles, a message is sent to the
mother’s brain; the hormone prolactin is produced, and travels to the
breast with a message to the gland tissue in the breast to ‘make milk’. If
the baby takes jaggery water or other fluids, the baby is not suckling and
the message to ‘make milk’ is not sent. This leads to less milk being made.
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
Feeding on Demand
Let the mothers be aware that they need to feed their babies on-demand.
o Definition of ‘on-demand feeding’: There is no schedule; when the baby
starts making a gentle sucking with its mouth, or moves its head toward
the breast, or cries, the baby should be fed. In the first few weeks
however, the baby needs to feed often; usually every 2-3 hours during
both the day and night. If the baby is sleeping, and has not fed in 4
hours, the baby should be waken up and fed.
o The reason for feeding the baby when he wants to feed; is to make sure
that the baby has the energy needed to grow. The baby does not grow
on a schedule, but when the baby is ready. As the baby suckles, a signal
is sent to the mother’s brain to ‘make more milk’ (suckling stimulates milk
production).
o By letting the baby suckle ‘on demand’ the amount of milk produced will
equal his need.
The reason to wake the baby if sleeping too long; is to prevent the milk supply from
decreasing. If the baby sleeps too long, and doesn’t suckle, the message doesn’t
go to the breast to ‘make more milk’. This can lead to a mother not having
enough milk. Also LBW babies needs to be fed more frequently, at least every two
hours.
__________________________________________________________________________
5.
FACTORS THAT MAY AFFECT BREAST FEEDING
Breastfeeding factors
Psychological
factors
 Poor
 Lack of
attachment
confidence
 Delayed
 Worry, stress
initiation of
 Dislike of
breast feeding
breast
 No night feeds
feeding
 Use of bottles
 Rejection of the
and or pacifiers
baby
 Infrequent feeds
 Interrupting
feeds
 Short feeds
Mother’s physical
conditions
 Contraceptive pill
 Pregnancy
 Severe
malnutrition
 Alcohol
 Smoking
 Retained
placenta
 Poor breast
development
 Tiredness
Baby’s
condition


Illness
Abnorma
lity
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6.
COMMON BREASTFEEDING PROBLEMS AND THEIR MANAGEMENT
Problem
Sore
Nipples
Causes:


Poor latch-on
Poor positioning
at breast
Management:








Not
Enough
Milk




Delayed initiation
of breastfeeding,
Infrequent
feeding,
Giving fluids other
than breast milk,
Anxiety,
Exhaustion,
Insecurity, Lack of
family support








Engorged
breasts
(very full
breasts)





Delayed initiation
of breastfeeding,
Infrequent
feeding,
Poor attachment,
Incomplete
emptying of
breasts,
Restricting the
length of the feeds






Improve attachment and/or position.
Continue breastfeeding (reduce engorgement if
present).
Build mother’s confidence.
Advise her to wash breasts once a day; do not
use soap.
Put a little breast milk on nipples after feeding is
finished (this lubricates the nipple) and air dry.
Wear loose clothing.
If nipples are very red, shiny, flaky, itchy, and
condition doesn’t get better with above
treatment, it may be a fungus infection
Refer to the nearest health facility.
Decide whether there is enough milk or not:
Is baby urinating six times or more per day if not it
means the baby is not getting enough milk
Has the baby gained sufficient weight? (In the
first week there is usually a small weight loss;
after that, a newborn should gain about 150–200
grams per week.) if not gaining weight the baby
is not getting enough milk
Reassure the mother.
Have the baby feed more often.
Observe breastfeeding to check for attachment
and positioning.
Encourage the mother to rest and drink and eat
more.
Praise her and ask her to return to the clinic for
follow-up visit.
Starting breastfeeding soon after delivery and
breast feeding often
Ensuring correct attachment
Encouraging on-demand feeding
If the baby can suckle, feed more frequently and
help with positioning.
If the baby is not able to attach, apply warm
compress to breast, gently massage from the
outside toward the nipple and express some milk
until the areola is soft. Then, put the baby to the
breast, making sure attachment is correct.
Have baby feed often to empty breasts. If not
able to, have mother express some milk herself.
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 If breasts are red and hard, CONTINUE TO FEED
OFTEN. Use warm gentle compresses to soften
them.
 Massage breasts toward nipple. Take the mother’s
temperature. If fever present, refer to the nearest
health facility. Continue to breastfeed from both
sides even if taking antibiotics.
Mastitis
(redness,
soreness,
lumps in
breast)





Delayed initiation
of breastfeeding,
Infrequent
feeding,
Poor attachment,
Incomplete
emptying of
breasts,
Restricting the
length of the feeds







Starting breastfeeding soon after delivery and
breast feed often
Ensure correct attachment
Encourage on-demand feeding
At first sign of redness or lumps in the breast, feed
more frequently to empty the breasts.
Use warm compresses and gently massage
breasts toward nipple.
Express milk if baby not able to empty breasts.
If fever, refer; continue breastfeeding both sides,
even if on antibiotics.
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Breastfeeding Problems: Diagnosis Form
Name of baby: ________________________________________________________
Name of mother: _____________________________________________________
Village: _______________________________________________________________
Date of delivery: ______________________________________________________
If any one of the following symptom is present, then make a tick (√ )
Days from birth
Days since birth
1
2
3
4
5
6
7
8
1. Baby’s suckling is weak or
stopped
2. Mother has no milk since
delivery
3. Baby not suckling well since
first day
4. Cracked nipple, engorged
breasts, painful breasts
Diagnosis: If one or more of the above symptoms are present, then the diagnosis is
“Difficulty in breastfeeding”.
Write treatment
How was the
condition of
Breastfeeding on
7th day?
On which day did
If not resolved, action
breastfeeding
taken
problem get solved
Signature of HSA: ____________________ Signature of NCS: ________________
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7. NEWBORN FEEDING OPTIONS FOR HIV POSITIVE MOTHERS
7.1 HIV/AIDS and infant feeding
All proven HIV +ve mothers need to be referred for infant feeding. The HIV-ve and
the unknown status will be counselled only on breast feeding
Exclusive breast feeding has been proved to reduce the risk of HIV transmission
through breast milk




90% of paediatric HIV is mother to child transmission (MTCT)
Mother to child transmission can occur during pregnancy, labour and delivery
and breast feeding
Breast feeding is norm to almost all mothers in Malawi
MTCT through breast feeding is 30-45%, if no interventions are taken
KEY POINTS
 Not all babies will get HIV from breast milk.
 Some of the babies will have been infected
with the HIV already during pregnancy and
delivery.
 However we cannot tell who will get HIV from
breast feeding.
 It is for this reason that every HIV +ve mother
needs to be counselled on infant feeding
options.
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7.2 FEEDING OPTIONS
World Health Organization recommends the following optimal infant feeding
practices:

Normal breast feeding
o Initiate Breastfeeding within 30 minutes of birth
o Exclusive Breastfeeding for the first 6 months of life
o Timely introduction of complementary feeding with continued
breastfeeding up to years and beyond

Early Breast Feeding cessation
Early breast feeding cessation is recommended as soon as replacement
feeding is; acceptable, feasible, affordable, safe and sustainable i.e. AFASS
A- Acceptable
F - Feasible
A - Affordable
S - Safe
S – Sustainable
Six months is the recommended age when the risk of replacement feeding is
decreased – but may not be absent)
 Replacement Infant Feeding
When replacement feeding is AFASS; breast feeding should be avoided to reduce
risk of HIV transmission to infants. However the replacement feeding needs to
provide all the infant’s nutritional requirements as completely as possible. Parents
must know all the advantages and disadvantages to be able to make an informed
choice
o Infant Formula
Advantages
–
No risk of HIV transmission if mother does not breastfeed at all
–
Specially prepared for the baby and contain most of nutrients the
baby needs
–
Other members of the family can help feed the infant
Disadvantages
–
–
–
–
–
–
–
Risk of diseases and malnutrition if not prepared correctly
Need to have recommended utensils
Need to have clean water and soap to wash utensils
No antibodies to protect the infant
No protection against pregnancy
Time consuming
Expensive
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–
Risk of stigmatisation
o Cow milk
Advantages
–
–
–
–
No risk of HIV transmission if mother does not breastfeed at all
Cheaper than infant formula
Easily available
Other family members can help to feed the baby
Advantages
–
No risk of HIV transmission if mother does not breastfeed at all
–
Cheaper than infant formula
–
Easily available
–
Other family members can help to feed the baby
KEY POINTS
There are several challenges associated with
newborn feeding options for HIV positive mothers
and these include;
 Counselling for infant feeding options
 Male involvement
 Introduction of PMTCT
 Introduction of ART for children
 Use of co-trimoxazole prophylaxis for HIV
infected children
 Social stigma
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SUB-UNIT 4.3 IDENTIFICATION AND MANAGEMENT OF LOW BIRTH WEIGHT BABIES
Specific Objectives
By the end of this sub-unit the HSA should be able to:
1.
2.
3.
4.
Identify a low birth weight (LBW) baby and a pre-term baby
Explain the risk factors of a low birth weight baby
Explain the care of the LBW baby.
Explain Kangaroo Mother Care (KMC) methods.
5. Demonstrate the ability to weigh a baby
________________________________________________________________________________
1. LOW BIRTH WEIGHT AND PRE-TERM BABY
1.1 Definitions:

A low birth weight baby is a baby born with a weight less than 2,500 grams
regardless of the gestational age.

A premature baby is a baby born before 8 months and 2 weeks.
_____________________________________________________________________________
Low birth weight can be due to pre-maturity or small for gestational age or
both.
1.2 Identification of a pre-term baby:
Physical Features of a Preterm Baby
PHYSICAL FEATURES
Weight
▫ Less than 2500 grams
Skin
▫ Thin with visible veins due to lack of fat under the skin
▫ May be covered with thick white cheese-like oily
substance (vernix) at birth
▫ Covered with fine, soft hair (lanugo)
Head
▫ Relatively large when compared with size of body
▫ Sutures and soft spot (fontanelle) are wide
▫ Ear has no cartilage before 25 weeks, the ear can be
folded and does not return immediately to the normal
place
Chest
▫ No breast tissue before 34 weeks of pregnancy
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Suck Reflex
▫ May be weak or absent
Legs/Arms
▫ May be floppy
▫ Legs mostly extended or minimally flexed
▫ Arms only occasionally flexed or even extended
Feet
▫ Foot creases on anterior 1/3 of foot
Genitals
2.
RISK FACTORS OF A LOW BIRTH WEIGHT BABY:




3.
▫ Small
▫ Girls: labia majora do not cover the labia minora
▫ Boys: testes may not have descended into the scrotum,
absent or few creases on scrotum
LBW infants loose body weight faster than normal babies as they have
difficulty maintaining their body temperature (less body fat, thinner skin,
bigger head relative to their body that loses heat fast and poor capacity to
generate body heat.
They are more prone to infection
Low birth babies may have difficulty breast feeding leading to weakness,
poor growth and ill health.
Pre-mature babies are at risk of jaundice (turning yellow) and if with very low
birth weight, bleeding in the head and death can occur
CARE OF THE LBW BABY
3.1
Keep the baby warm





Keep room even warmer than usual
Dry baby immediately after birth
Incubator care
Put baby in Kangaroo Mother Care (KMC) position
If skin to skin not possible, put on baby clothes, hat and place in a
warm blanket or warm bag
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3.2
Observe extra hygiene
3.3
Feeding of low birth weight or pre-mature




Preterm and low birth weight babies needto be fed frequently in small
quantities
Preterm and low birth weight babies need exclusive breastfeeding
If the baby is 2000 grams or above and is healthy, the baby can be
kept at home with extra care including extra weekly visits
Some very small babies cannot suckle from the breast. Mothers can
express their breasts and feed the baby breast milk with a cup.
Technique on how to express breast milk
How the Mother Can Express Milk by Hand
1. Wash hands with soap and water.
2. Place a warm compress on the breast for a few minutes if desired.
3. Gently massage the breast starting from the chest moving toward the
nipple; do this in a circle (near the underarm, and then to the bottom of
the breast, etc.), so that all parts of the breast are massaged.
4. Lean forward and support the bottom of the breast with one hand.
5. Hold the areola between thumb and two fingers of other hand. Put her
thumb on the areola above the nipple and the two fingers on the
areola below the nipple.
6. Press toward the chest (about 1-2 cm) and then squeeze the milk
reservoirs beneath the areola. (Do not squeeze the nipple.)
7. Press and release the thumb and first finger several times until the milk
drips out. Use a clean bottle or cup to collect the milk. Milk may drip at
the beginning and then spray out after the milk starts flowing.
8. Rotate the thumb and fingers around the areola so that the milk is
removed from all the reservoirs.
9. Repeat with other breast.
Adapted from Breastfeeding Management and Promotion in a Baby-Friendly
Hospital, UNICEF and WHO 1993.
Replace the first picture on expressing
breast milk
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Small babies get sick easily: if danger signs arise it is important to seek care
immediately
4.
KANGAROO MOTHER CARE (KMC) METHOD
4.1 Definition of KMC
This is a method used for caring for low birth weight babies weighing less than
2000g (2KG). The newborn is placed skin-to-skin between the mother’s breasts and
stays that way for as long as possible during the day and night. This method
includes keeping babies warm and feeding them as needed.
4.1 Steps in positioning the baby in KMC
1. Dress the baby in socks , nappy and cap
2.
3.
4.
5.
Place the baby between the mother’s breast
Secure the baby into the mother’s chest with a cloth
Put a blanket or a shawl on top for additional warmth
Instruct the mother to put a front opened top ( a top that opens at front to
allow the face , chest abdomen, arms and legs of the baby to remain in
continuous skin- skin contact with mother’s chest and abdomen
6. instruct the mother to keep the baby upright when walking or sitting
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7. Advise the mother to have the baby in continuous skin to skin contact 24 hours
a day or less in the case of intermittent KMC
8. Advise the mother to sit in Half – sitting position to maintain the baby in a
vertical position
9. Breast feed often (every 2 hours). Use the opposite under arm position. if unable
to breast feed, express milk and feed by cup
KEY POINTS
Small babies need to feed often, that means the mother should wake
the baby, if the baby sleeps more than 2 hours. This should be done
until the baby gains some weight and is stronger.
 Small babies lose weight in the first few days after birth, as their
bodies lose extra water in the transition from the amniotic fluid
environment.
 It is normal for babies to lose up to 10 percent of birth weight.
 Weight loss of up to 10 percent in the first few days of life is
considered acceptable.
 After this initial weight loss, newborn babies begin to gain
weight steadily and usually regain birth weight seven to
fourteen days after birth.
 No weight loss is acceptable, after this initial weight loss period.
 Babies should be weighed weekly.
 Schedule these weight assessments on the same day each
week until the baby is attains 2500g.
Exercise:
Case Situations on care for Low birth weight babies
1. Baby Amina is born at 7 months; she weighs 1.6 kg.
a) What do you say about the baby’s gestation and weight?
b) What would you do for the baby?
1)
2)
3)
4)
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c) Explain the Kangaroo method and why it is advised for small babies:
2. Baby Chisomo is born at 8 months and 17 days and weighs 1.8 kg. You do the
exam during the first home visit on day 1. The baby is doing well. He is feeding well
and his temperature is normal. What would you tell the mother before you leave
for home?
a)
b)
c)
d)
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5. Procedure for weighing a baby
1. Place sling on scale, hook with a cloth, clothes or nappy like what the baby is
wearing
2. Hold scale by top bar off the floor, with adjustment knob at eye level.
3. Turn screw until the top of the screw fully covers the red and “0” is fully visible.
4. Remove sling from hook and place it on a clean cloth on the ground.
5. Place baby in sling with minimum clothes and replace sling on the hook.
6. Holding top bar carefully, lift the scale and sling with baby off the ground as
you stand up, until knob is at eye level
7. Read the weight (to nearest 50 grams).
8. Gently put the sling with baby on the ground and unhook the sling.
9. Remove the baby from sling and give to mother
10. Record the weight and give feedback to the mother.
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SUB UNIT 4.5 POSTNATAL HOME VISITS
Specific Objectives
By the end of this sub-unit the HSA should be able to;
1 Explain when and why an HSA should visit a postnatal mother and newborn
baby during the post natal period.
2 Explain the sequencing of tasks during the post natal visit
3 Outline the tools used during the post natal visits.
4 List the danger signs of the mother and the newborn baby during the
postnatal period
5 Complete the Post natal home visit form
6 Use the screening and counselling cards and referral notes during the
postnatal Home visits
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1.
POSTNATAL VISITS
1.1
When Postnatal Visits Should Be Conducted
The HSA should visit postnatal mothers and newborn babies on the
following visit days;



1.2.
It is best to make the first visit before 48 hours.
Best day is day 1.
Make the visits two times more during the first week; days 3 and 8
Why Postnatal Visits Should Be Conducted
The HAS should conduct postnatal visits for the following reasons;

Mother
o To screen for mother’s health, using the screening card:
o To take temperature if needed.
o To give specific advice/referral as required

Baby
o To screen for Baby’s health, using Screening card:
o To take temperature.
o To weigh the baby (if not weighed at birth).
o To count respirations.
o To give specific advice/referral as required
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o To review danger signs, using counselling cards and promote
breastfeeding among other issues
o Make two more visits (if LBW baby and if discharged from
hospitals); one more visit in the first week and one during the
second week. Using the “Care of the LBW newborn counselling
card” review the care of the baby on the first visit and during the
subsequent visits
________________________________________________________________________________
2. THE SEQUENCING OF TASKS DURING THE VISIT
For proper performance of tasks during the postnatal visit the following
sequence should be followed;












3.
Greet the mother
Ask about well being, make general conversation
Take out the necessary equipment from bag and place them on a
clean cloth
Wash your hands
Collect mother’s information (using mother’s Screening Card and
Referral Note if needed)
Collect newborn’s information (using baby’s Screening Card and
Referral Note if needed)
Examine the baby
Counsel the mother and the baby’s on their conditions as needed.
Use Counselling Cards appropriately as detected by the situation (e.g.
on breastfeeding, LBW, etc.)
Talk to the mother about danger signs in the baby and herself if any
Praise the mother and reinforce positive behaviours
Finally complete the Postnatal Home Visit Form
TOOLS USED DURING THE POSTNATAL VISITS
Tools used during the postnatal visits are as outlined below;
Card 2: Nutrition
Card 7: Breast feeding
Card 9: Family planning
Card 10a): Common maternal danger signs
Card 10b): Common newborn danger signs
Card 11: Kangaroo Mother Care
Card 12: On going care of babies
Card 13: On going care of mothers
First home visit after
giving birth
Second and third
home visits after
giving birth
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4. DANGER SIGNS OF THE MOTHER AND THE NEWBORN DURING THE POSTNATAL
PERIOD
4.1
Danger Signs in mothers after delivery (Post Partum)
KEY POINTS
 When dealing with danger signs from the
mother refer to the counselling cards
(cards 8 and10a)
 Two danger signs;
o Excessive vaginal bleeding and
High fever are shown in
red/pink on the screening card
 This indicates they are life threatening.

Excessive bleeding
o Ask the mother how much bleeding she is having (it should be less than the
day before, and getting less red as the time goes after delivery)
o Ask her if her womb feels ‘hard’. This hardness is actually the womb
contracting, and it should be getting smaller each day after delivery (until it
disappears)
o If she says she is bleeding a lot then she should go immediately to the
hospital
What to do:

Under “What to do” on the counselling card, there is an icon showing a hospital
meaning immediate referral.
o Post partum haemorrhage can be life threatening – a woman can die in 2
hours. Most of the post-partum haemorrhage (PPH) is from a uterus that has
not contracted. Sometimes there is bleeding from a cut or laceration. This
blood is usually very bright red. In either case the woman needs to be sent
to the hospital immediately.
o You can put the baby to the breast to try and contract the womb
o Encourage the woman to urinate (this sometimes helps the womb to
contract)
o Ask the mother or the guardian to rub the top of the womb
_____________________________________________________________________________
Failure of the uterus to contract results in severe bleeding. This is the commonest
cause of bleeding after child birth
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 High fever
Ask and observe the mother
Fever is a sign of infection. Post partum infection is one of the top causes of
maternal death after delivery. Fever can also be a sign of malaria, or a breast or
urine infection. Take the mother’s temperature. If fever is over 380C refer.
o Ask if the mother feels hot or feverish
o Take her temperature
o Ask if mother has foul smelling discharge
What to do:
Under “What to do” on the counselling card, there is an icon showing a hospital
meaning immediate referral.
________________________________________________________________________________
If the mother has any one of these two danger signs, she must be referred to a
health facility immediately.
________________________________________________________________________________


Breast problems
Ask, Observe
o Ask if the baby is suckling well
o Ask if she has engorgement, cracked nipples etc
o Note if the baby is low birth weight
o Observe by weighing the baby
What to do:
o Observe the mother breastfeed and decide what the problem is,
o Counsel mother on how to resolve problem.
o If not resolved in a day or two, refer to the health facility.

No problems
What to do:
If there is no problem detected the HSA should praise the mother and continue
with health education specific for post partum period.
4.2 Danger Signs in the Newborn
KEY POINTS
 When dealing with danger signs on the newborn refer to
the counselling cards (cards 8 and10b)
 Six danger signs are shown in red/pink on the screening
card ;
o This indicates they are life threatening.
 Two danger signs are shown in yellow on the screening
card;
o This indicates they are dangerous conditions
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
Not able to feed
Ask and Observe
o Ask if the baby is not feeding or feeding less (half of what the baby was fed
before)
o Observe and ask the mother to try breastfeed the baby.
What to do:

Under “What to do” on the counselling card, there is an icon showing a hospital
meaning immediate referral.

Moves less, sleepy, lethargic
Ask and Observe
o Ask if the baby moves less than usual or is very sleepy. A baby is considered
to be moving less than normal when it sleeps a lot and can’t wake up or
seems drowsy
o Observe the baby and try to arouse him
What to do

Under “What to do” on the counselling card, there is an icon showing a hospital
meaning immediate referral.

Too Cold or feverish
Ask and Observe
o Ask the mother if the baby feels colder or hotter than normal
o Observe by taking the baby’s temperature
What to do:

Under “What to do”
o If temperature is 37.50C and above refer immediately
o If the baby is cold, temperature below 36.50C, place skin to skin and
re-warm.
o If after two hours of re-warming the temperature is still below 36.50C
refer immediately in Kangaroo Mother Care (KMC) position.
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 Fast breathing (60 or more breaths per min)
Ask and Observe
o Observe by counting respirations when baby quiet.
o Repeat the count if rate is 60 or more per minute to confirm fast breathing .
What to do

Under “What to do”

o A respiratory rate of 60 breaths or more per minute shows signs of
pneumonia. Refer immediately.
Umbilical discharge with redness extending to surrounding skin
Ask and Observe
o Ask the mother if navel is red or has pus
o Observe by checking the navel
What to do:

Under “What to do”
o If there is pus, it is a sign of local infection.
o Refer for treatment as it could worsen and become life threatening

Convulsions
Ask and Observe
o Ask the mother if baby has had any abnormal movements either of the
entire body or part of the body (fits)
What to do:

Under “What to do”
o Refer immediately

Eyes with pus or history of eyes discharging pus
Ask and Observe
o Ask the mother if she has observed pus in the eyes of the child especially
early in the morning
o Observe if the baby has pus in the eyes. This can be a sign of local infection
or severe infection
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What to do:

Under “What to do”

o Refer for urgent treatment.
Premature or Low birth weight
KEY POINTS
 A baby weighing less than 2500 grams (2.5Kg)
has low birth weight (LBW).
 Premature babies are generally LBW.
 LBW babies are at greater risk of infection or
feeding problems due to small size.
Ask and Observe
o Ask the mother the weight of the baby
o Observe by checking documentation of the baby’s weight
o Weigh the baby
What to do:

Under “What to do”
o Start Kangaroo Mother Care (KMC)
o Give extra care (refer to notes on premature/very small baby
o If the baby is not in distress, assist with feeding if needed and
encourage KMC
o Visit one more time in 1st week and once in 2nd week
o If the baby is in distress, then refer to a health facility immediately

Jaundice
This is the yellow colouration of the skin especially in the eyes
Ask and Observe
o Observe if the baby has yellow colour in the eyes and the skin
What to do:

Under “What to do”
o Refer to the health facility
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 Pustule
Ask and Observe
o Ask the mother if there are any skin swellings discharging pus on the body
o Observe for pustules by inspecting the whole child
What to do

Under “What to do”
o Refer to the health facility
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5.
COMPLETING THE POST NATAL HOME VISIT FORM
Delivery and Postnatal Home Visit Form
Delivery
Name of Mother: _________________________________ EDD: ________________________
Actual date of delivery: ____________________________ Time: _______________________
Name of newborn: ________________________________ Sex: Boy/Girl _________________
Place of delivery __________________________________
Was mother transferred to facility for danger sign? Yes/No
Baby a live birth or stillbirth? Live birth ___________ Stillbirth ___________
Immediate care (if CHW present)
____ dried, skin to skin, covered
____ baby checked: Is baby breathing normally? Yes ______ No ______
If no what
wasdone?______________________________________________________________
____ breastfeeding within 30 minutes of birth
____ cord hygienically cut and dry
____ birth weight _________ grams Is baby LBW? Yes ______ No ______
____ tetracycline in both eyes
Postnatal home visits
(Count “0” for the day of delivery and the day after delivery as Day 1)
1st visit: Day_______________ 2nd visit: Day ____________ 3rd visit: Day____________
1. Screened mother for danger signs? Visit 1 ________ Visit 2 ________ Visit 3_______
2. If referral made, make note of date and reason:
Date:
Reason:
3. Screened baby for danger signs? Visit 1 __________ Visit 2 ________ Visit 3_______
4. If referral made, make note of date and reason:
Date:
Reason:
5. If no referral, what action was
taken?______________________________________________
6. Weight (if not done at birth): _________________ grams/kg done on
Day______________
7. Is baby LBW? Yes _____ No _____. If yes, make two extra visits and use LBW
Counselling Card
Week 1: Date of extra visit __________________________________ Day
Week 2: Date of extra visit __________________________________ Day
8. Other problems/advice given:
9. Congratulations brochure given? Yes _____ No _______
10. Counselling Cards used: Visit 1 ______ Visit 2 _____ Visit 3______
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6.
USING THE SCREENING, COUNSELLING CARDS AND REFERRAL NOTES DURING
THE POSTNATAL HOME VISITS
6.1. Screening card

The use of screening cards is as shown on danger signs
6.2. Counselling cards

The use of counselling cards is as shown on danger signs
6.3. Using of Referral Notes
If a danger sign is found, it should be explained to the mother
The name of the mother is then filled and the problem circled on the card.
The Referral Notes for women have two icons.
o One for a pregnant woman
o The other for a woman after delivery.
o If the referral is after delivery, circle the icon with the non-pregnant
woman.
o Under the name of the mother, write the risk sign (or signs) that were
found.
 Both sides of the referral note must completed,



o One side is torn off and given to the family to present at the health
facility.
o The other side is kept for the HSA record (and for the supervisor to review).

If the programme is not using a Referral Note,
o The HSA can write a note to the nurse at the health centre explaining
what he found as wrong on the mother.
_______________________________________________________________________________
In addition to identifying mothers or babies with danger signs, you must be
sensitive to any individuals or groups whose voices are unlikely to be heard. You
must find ways of reaching out and listening to them
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UNIT 5: MANAGEMENT OF SUPPLIES, RECORD KEEPING, SUPERVISION
The Purpose of this unit is to equip HSA with knowledge and skills on how to record
and maintain information during and after home visit. The unit also prepares the
HSA with supervisory skills necessary to supervise their subordinates.
Objectives
By the end of the session the HSAs and their supervisors should be able to;
1. record information using the forms and NBH pilot registers
2. understand reporting lines (flow of information) and use of data in the district
3. Maintain records and keep supplies
4. Highlight areas that will be supervised and how supervision will take place
A. Documentation
The following information is expected to be documented by the H.S.A or the
supervisors
 Background information for each H.S.A who has just joined the program and
about to start CBMNH work
 Antenatal and postnatal care information upon conducting home visits
 Community mobilization information upon conducting community
mobilization activities
 Performance of the HSAs and the program in general upon filling a
supervision checklist and writing supervision reports
 Success stories and challenges experienced by both the HSAs and the
supervisors in CBMNC program
List of Forms to be filled and kept;
1. HSA Background Information Form
2. Community mobilization activities form
3. Women of child bearing age list form (to be filled in communities where
there are no village registers)
4. Pregnant women list (to be filled in communities where there are no village
registers)
5. Home visit – Antenatal Care Form
6. Home visit – Postnatal Care Form
7. Newborn Health Pilot register
8. Supervision checklist
Records:
All records (home visit registers/forms, community mobilization forms, list of
women of child bearing age, list of pregnant women etc) should be kept safe.
It is recommended to keep records at places where they cannot be damaged
by children, fire, water etc.
 Information collected would be used to:
– Reflect progress
– Guide management and other stake holders in decision making on
how to effectively implement the CBMNH program
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District Level Forms Flow Chart
District team analyses data
& provides quarterly reports
& feedback to health
facilities/RHU. Also
coordinates sending of data
to RHU/Represe-ntative
monthly for backup/cleaning/analysis etc
RHU/Representative receives
data, reports. Does further
analyses and provides
feedback.
CBMNC Coordinator receives, cleans and
sends data for entry to the HMIS
HSA’s Supervisor receives, cleans and
submits forms to CBMNC coordinator
by the 15th of the month
HSA fills in forms &
submits to
immediate
supervisor by end of
the month
Note: Timely feedback is to be provided at all levels.
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B. Supplies and Equipment
Supplies and equipment should be well kept. Here are some tips:
 Label all supplies.
 Keep supplies away from children.
 Keep weighing scale and thermometer in their boxes for extra protection.
 Clean the thermometer (about ½ finger length from the tip) after each use
with a cotton ball and spirit (alcohol).
 Wipe scale from time to time with damp cloth.
 If the thermometer battery gets low ask the supervisor for another one
C. SUPERVISION OF SUBORDINATES
The HSA reports to:
o Supervisor (Health Centre- in charge)
o District supervisor point person
The HSA supervisor reports to management on what the HSA does in the
Community
Supervision of HSA and the assessment of their performance



HSA will be supervised monthly by their immediate supervisors at health
facility level, using a supervision checklist .
The supervisors will be using a supervision checklist to ensure consistency.
They will also be discussing with the HSA on data collection upon reviewing
the forms.
The district supervisors will be supervising the health centres and HSA once in
a quarter also using checklists.
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Annex 1: Supervision Checklist for HSA
1.
Name of Health Facility: ___________________________________________
2.
Name of HSA: ____________________________________________________
3.
Names of intervention villages: _____________________________________
4.
Total population of villages: _______________________________________
5.
Name of Supervisor: ______________________________________________
6.
Date of Supervision: ______________________________________________
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Instructions
Use this checklist to assess HSA’s performance in community based maternal and newborn care. The
checklist itemizes all the areas that should be supervised. In filling in this checklist, the supervisor is
expected to physically check or observe the activity/item being supervised. Under checklist column, you
either tick (√ ) for an activity/ item that has been perfectly done, write an X for an activity/item not done or
write N for an activity/item that you failed to observe during the supervision. The comments column is for
any additional information you may have regarding how the activity/item was done. Supervisors are
expected to supervise ALL the activities/items
Verification Area
Activity (Item) observed
1) Prepares the ‘List of
Women Who Can Get
Pregnant (women of child
bearing age)’
1.1. Correctly calculates and records the
Age of the women on the HSA Home
Visiting Form.
1.2. Writes and/or maintains a list with
the names of women of child bearing age
in the entire village.
In each home visited, names of all
eligible women entered on the list.
2.1 Writes and/or maintains a list with the
names of all currently pregnant women in
the village.
2.2 Asks for and records the woman’s
Last Menstrual Period (LMP) on the HSA
Home Visiting Form.
2.3 Correctly calculates the Expected
Date of Delivery (EDD) based on the
LMP (2.2), and records this on the Home
Visiting Form.
3.1 Schedules 3 home visits during the
woman’s life of pregnancy.
3.2 Records the dates of the 3 scheduled
home visits on the Form “List of Pregnant
Women” and on their calendar.
Good communication skills
Greets the pregnant woman and
introduces himself/herself appropriately.
Explains why s/he is visiting today.
Establishes rapport with mother before
beginning session.
Acts with confidence when
communicating the topics at hand.
Speaks in a gentle tone of voice.
2) Prepares the ‘List of
Pregnant Women’
3) Target Visits
4) Demonstrates ability to
perform home visits
Checklist
(√ = done
X = not done
N = not observed)
comments
Uses simple words (lay terms) in the local
language to describe complex issues.
Uses training aids as appropriate,
according to the timing of the visit.
Is respectful and makes the mother feel at
ease.
Asks the woman if she has any questions.
Answers the woman’s questions clearly.
Thanks the woman for her time during the
visit.
Reminds the woman when s/he will
return for the next visit.
Hand Washing
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Verification Area
5) Uses screening
cards/referral notes and takes
action as appropriate
Activity (Item) observed
Checklist
(√ = done
X = not done
N = not observed)
comments
Rinses hands with water
Applies soap and scrubs hands together.
Rinses hands with clean water.
Air dries hands by keeping hands in the
air.
Home Visit
5.1 Correctly identifies the appropriate
screening cards/referral notes that should
be used according to mother’s
gestation/month of pregnancy.
Months 1-3: Uses screening cards 1-4
Months 4-6: Uses screening cards 5-7b
Months 7-9: Uses screening cards 1-9
5.2 Introduces sub-topics of each
screening card that is used.
6) Displays knowledge of
Birth Plan and Birth
Preparedness
5.2 Asks open ended questions using the
screening cards as a guide.
5.3 Uses paraphrasing techniques to
summarize key issues discussed by
mother.
6.1 Asks mother is she has a birth plan.
6.2 If yes, checks birth plan for
completeness.
A complete birth plan includes:
- Transport arrangement
- Place of delivery (health facility)
- Guardian to accompany mother
- Guardian to stay at home and take care
of children
- Clothes for newborn
- Money in case of emergency
- Plan to arrive early at facility
6.3 If not complete, identifies gaps in
mother’s birth plan and makes
recommendations.
7) Weighing
Weighing the baby
7.11. Places sling on scale hook with
cloth, clothes and nappy as worn by the
baby
7.2. Holds scale by top bar, off the floor,
with adjustment knob at eye level.
7.3. Turns screw until the top of the screw
fully covers the red and “0” is fully
visible.
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Verification Area
8) Temperature
Activity (Item) observed
Checklist
(√ = done
X = not done
N = not observed)
comments
7.4. Removes sling from hook and places
it on the ground.
7.5. Places baby in sling with minimum
clothes and replace sling on the hook.
7.6. Holds top bar carefully, lifts the scale
and sling with baby off the ground until
knob is at eye level.
7.7. Reads the weight to nearest 50
grams.
7.8. Gently puts the sling with baby on
the ground and unhooks the sling.
7.9. Removes the baby from sling and
gives baby back to mother.
7.10. Records the weight and gives
feedback to mother.
Taking temperature
8.1. Takes thermometer out of box,
holding it at the broad end and cleans the
metal tip with cotton.
8.2. Press the button one time to turn the
thermometer on.
8.3. Correctly takes baby’s
temperature using the thermometer
9) Counting respirations
10) Help mothers breastfeed
effectively
11) Help mothers keep babies
warm
8.4. Record the temperature reading on
the form.
8.5. Turn the thermometer off by pushing
pink button one time.
8.6. Clean the shining tip of the
thermometer with cotton soaked with
spirit
8.7. Place thermometer in storage case.
Counting Respirations
9.1. Waits for child to be quiet/stable
before beginning to count respirations.
9.2. Removes watch and holds it in one
hand, close to baby’s abdomen.
9.3. Lifts the baby’s shirt to observe the
rising and falling of the abdomen.
9.4. Counts respirations for 1 minute and
repeats after getting a 60 or more count
per minute.
9.5. Records number of respirations per
minute on form.
Helping Breastfeeding
10.1 Discusses and encourages early
initiation of breastfeeding with mother.
10.2 Counsels mother on breastfeeding
practices and danger signs.
10.3 Observes proper latch-on,
positioning and burping of newborn.
Keeping babies warm
11.1 Discusses the importance of keeping
newborns dry and wrapped
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA
MATERNAL AND NEONATAL HEALTH
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Verification Area
Activity (Item) observed
Checklist
(√ = done
X = not done
N = not observed)
comments
11.2 Checks that baby is wearing a hat,
loose clothes, and is warmly
wrapped.
If not appropriately clothed and wrapped,
assists mother to clothe and wrap the
baby appropriately.
12) Care for Low Birth Weight
and high risk
13) Stock
14) Maintains adequate recordkeeping
11.3 Discusses the importance of
delaying bathing the baby by one day
Care for low birth weight and high risk
12.1 Identifies LBW and high risk babies
and plans accordingly for 2 extra visits
12.2 Provides extra care: Skin to skin,
assist with feeding, extra hygiene
12.3 Counsels family on danger signs of
LBW and high-risk babies.
Stock of equipment, supplies and drugs
13.1 Keeps stocks in a clean and dry
location.
13.2 Checks that medicines are kept away
from children.
13.3 Checks that medicines are well
labeled.
13.4 Checks that equipment is clean and
stored in their box.
13.4 Checks that all equipment is in
working condition.
13.5 Correctly and consistently completes
the stock register. Maintains the register
as appropriate.
Maintains adequate records of all home
visits.
14.1 Documents information from home
visit correctly and appropriately where
necessary.
14.2 Files the forms/records together in a
safe place.
14.3 Compiles and submits completed
forms in a timely manner.
Final Comments/ observation: (state how the HSA is working in terms of knowledge of subject of
discussion, confidence, counseling skills, rapport with client etc qualitatively)
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COMMUNITY BASED MATERNAL AND NEONATAL CARE TRAINING MANUAL FOR HSA