Essential Nutrition, Hygiene, and Care Practices during...

Essential Nutrition, Hygiene, and Care

Practices during Pregnancy

Lesson Plan

Module 2 of 5

2

Essential Nutrition, Hygiene, and Care Practices during

Pregnancy

Table of Contents:

Lesson 1: Antenatal Care and Centre de Santé Births.......8

Lesson 2: Maternal Nutrition.........................................18

Lesson 3: Micronutrients (Iron and Iodine)....................27

Lesson 4: Hand washing with Soap (or Ash)..................37

Lesson 5: Household Hand Washing Stations.................47

Lesson 6: Malaria Prevention.........................................56

Lesson 7: Preparing for Delivery and Birth.....................66

Lesson 8: Immediate Breastfeeding...............................76

Lesson 9: Newborn Care Practices.................................86

Lessons, stories, and activities in the Essential Nutrition, Hygiene, and Care Actions during Pregnancy Lesson Plan complement the information provided in the Essential Nutrition, Hygiene, and Care Actions during Pregnancy Leader Mother Flipchart.

Understanding the Lesson Plan

Each lesson begins with objectives. These are the

behavior, knowledge and belief objectives that are covered in the lesson. Make sure that each of these

objectives is reinforced during the lesson. There are four types of objectives. Each is described below.

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

Knowledge objectives: For example, we want mothers to be able to name the

danger signs as well as the five ways that diarrhea-causing germs are transmitted. These are facts that the caregivers must memorize during the

lesson, using the pictures as a reminder. Belief objectives: We know that beliefs and attitudes affect our practices.

Many times it is a person’s inaccurate belief or worldview that hinders them from making a healthy behavior change. In this module we are reinforcing the belief

that change is possible. We also have a lesson devoted to discussing child value.

Behavioral determinant objectives: Behavioral determinants are reasons why people practice (or don’t practice) a particular behavior. There are eight

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possible behavioral determinants as identified in the Barrier Analysis1 surveys done in each region. The surveys identify the most important determinants for

each behavior. By reinforcing the determinants that have helped the doers (caregivers in the community already practicing the new behavior) we are able

to encourage the non-doers (caregivers who have not yet tried or been able to maintain the new practices). We also help non-doers (caregivers who are not practicing new behaviors) to overcome obstacles that have prevented them from

trying or maintaining the practice in the past. Behavioral determinants will be more prominent in future modules.

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

Lesson 5, we introduce the idea of an Activity Leader who will focus on the needed materials for Module 2. See below for more information.

Each exercise (section of the lesson plan) is identified by a small picture. Pictures are used to remind non-literate Mother Leaders of the order of the

activities. For example when it’s time to lead the game the lesson plan shows a picture of people laughing as if they are enjoying a game (see below). The

pictures in the lesson plan help to cue Mother Leaders of the next activity. Review the descriptions below for more information.

The first activity in each lesson is a game. Games help the participants to laugh, relax and prepare for the

lesson. Some games review key messages that the participants have already learned. Some games promote the belief objectives. Make sure that everyone

participates in the games.

Following the game is the attendance and troubleshooting section. All facilitators will take attendance. The troubleshooting questions only apply to

facilitators (promoters) training others.2 The promoter follows up with any difficulties that the Mother Leaders

had teaching the previous lessons. Refer to the role play in Lesson 4 for more information.

Next the facilitator opens the flipchart to the first picture of the lesson. He or she reads the story printed on the back of the flipchart, adding more details and

descriptions as desired.

1 See http://barrieranalysis.fhi.net for more information. 2 In the Tubaramure program, paid staff are called promoters. The role of the promoters is to

train Mother Leaders to facilitate lessons with their neighbors. A few exercises, noted above, are only for promoters and do not need to be used by the Mother Leaders when sharing with their neighbors.

http://barrieranalysis.fhi.net/

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The story in each lesson is followed by discussion

questions. These questions help the facilitator to find out the caregivers current practices (related to the lesson). This section is marked by the A (ask) in the ASPIRE

method.3 This section is meant for discussion, not for teaching. Be sure to let everyone voice their opinions

The second, third and fourth picture in each lesson

are for teaching the key objectives of the lesson. After turning to the second flipchart page [the S (Show) - in

ASPIRE], ask “What do you see in this picture?” Let the participants respond and describe what they think the flipchart pictures are telling them.

Next, explain the key messages written on the back of the flipchart. The key

messages also appear as captions on the flipchart pages. Be sure to explain each picture using the additional bullets printed on the back of the flipchart (or

in the lesson plan). The lesson plan also contains additional information for the trainer. The additional information does not need to be discussed during the

lesson unless it directly relates to questions by the participants.

After the fourth picture of the lesson, is an activity. Activities are “hands-on” exercises to help the participants understand and apply what they have

learned. Most of these activities require specific materials and preparations.

Beginning in Module 2, an activity leader is responsible to organize materials for

the Lesson Activity. The Activity Leader for Module 2 is elected in Lesson 5. The Activity Leader meets with the facilitator ten minutes before each lesson to

discuss the needed materials for the next lesson’s activity. The Activity Leader is responsible to talk with the others (Mother Leaders or neighbors) during the “Attendance and Troubleshooting” to organize the materials needed for the next

meeting, asking them to volunteer to bring the items. The facilitator will lead the activity, but the Activity Leader will support her by organizing the volunteers

and aiding the facilitator as needed during the activity. After the activity, the facilitator completes the P-I of the ASPIRE method.

The ASPIRE method is used to reinforce participatory methods of teaching. It is explained in detail in Lesson 2.

3 For more information about the ASPIRE method review Lesson 2.

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In the probe section the facilitator asks if there are any

obstacles that may prevent the caregivers from trying the new practices. They discuss these obstacles and then move to the next section.

The facilitator informs the caregivers of ways to overcome the concerns that are mentioned. The facilitator gives more information or a different

perspective to help the caregivers understand how to move forward.

Next is Practice and Coaching. This section is required for the training of Mother Leaders. We want to make sure that they understand the material and can present it to others. In this small group activity, the promoter can observe

and coach those who are having difficulty.

Finally the facilitator completes the R-E of the ASPIRE method.

The facilitator requests a commitment from the Mother Leader (or caregivers) to begin practicing the new

practices they have discussed. If they agree, the caregivers should make a verbal commitment. It is up to the caregivers to make a choice. They should not be

forced to make a commitment if they are not ready.

The last section is where the facilitator examines the Mother Leader (or caregivers’) practices based on the teaching from the last lesson. The facilitator encourages

them to try the new practices they have not yet done.

All lessons follow the pattern described above. Lessons can be adapted as needed to fit the needs of your care group. Lessons should not exceed two

hours in length although some lessons may take longer than others. The suggested time for each section is listed below.

Section name Time needed for this section

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Game

Attendance and Troubleshooting Story and Ask (picture 1) Show and Explain (picture 2)

Show and Explain (picture 3) Show and Explain (picture 4)

Activity Probe Inform

Practice and Coaching Request

Examine

10 minutes

5- 15 minutes 10 minutes 5 minutes

5 minutes 5 minutes

15 minutes 10 minutes 5 minutes

20 minutes 2 minutes

15 minutes

2 hours

Acknowledgements

Hanold, Mitzi J. (2009) Care Group Orientation Mother Leader Lesson Plan. Washington DC. Food for the Hungry (FH), made possible through support

provided by the Office of Food for Peace, Bureau of Democracy, Conflict, and Humanitarian Assistances, and the U.S. Agency for International Development

under the terms AID-FFP-09-00004-00. The opinions expressed herein are those of the author and do not necessarily reflect the view of the U.S. Agency for International Development.

Many thanks to our illustrators Octávio Consalves and Petra Röhr-Rouendaal. Editors include Carolyn Wetzel (FH), and Mary Hennigan (CRS), Deanna Olney (IFPRI). For questions or comments, please contact the author at [email protected].

Resources used in the development of this module include the following:

Beck, Diana, et al. Care of the Newborn: Reference Manual. DC: Save the Children, 2004.

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

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

Rohr-Roendaal, Petra. Where There is No Artist. Development drawings and how to use them. London, UK: Intermediate Technology Publications,

1997. 100 ways to energize groups: games to use in workshops, meetings and

the community. Available at www.aidsalliance.org. International

HIV/AIDS Alliance, 2002.

http://www.aidsalliance.org/

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Lesson 1: Antenatal Care and Centre de Santé

Births

Pregnant women will visit the health center at least three times during

pregnancy starting at the first sign of pregnancy. Prenatal visits are recommended once each trimester.

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

o Antenatal visits (visits before birth) ensures that the infant is growing well in the womb and the mother remains healthy.

Caregivers will be able to describe the services provided during an antenatal visit.

o The health worker will measure the growth and position of the baby by

measuring the woman’s belly.

o The health worker will offer supplements (iron and folate vitamins) to

the mother to prevent physical and mental problems for the infant.

o The health worker may vaccinate the mother to protect her and the

infant from tetanus.

o The health worker will examine the infections that harm the infant including:

o Parasites which cause anemia (hookworm and malaria)

o Sexually transmitted infections and HIV.

o Toxemia (high blood pressure and swelling of hands and

face).

o The health worker will give treatment when infections are discovered.

o The health worker will examine the woman to determine if she has

sickness or conditions that might per her or her child at risk of death during delivery.

Caregivers will make a birth plan for delivery.

o Caregivers will save money for transportation to the Centre de Santé.

o Caregivers will gather clean clothes for the mother and infant. The

mother may also need clothes to absorb bleeding after delivery.

o Caregivers will bring food and water for the mother after delivery.

o Caregivers will arrange with someone to take care of older children and

the household while the mother is away for delivery.

Materials:

1. Attendance Registers for Mother Leaders

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Lesson 1 Summary:

Game: People to People

Attendance and Troubleshooting

Share the story and ask about current behaviors: Visiting the Centre de Santé

Show pictures and share key message on flipchart pages 6-11 about

Antenatal Care during Pregnancy, Services provided by the Centre de Santé, and Preparing a Birth Plan.

Activity: Making a Birth Plan

Probe about possible barriers

Inform them of possible solutions to the barriers

Practice and Coaching in pairs

Request a commitment

Examine commitments and behaviors related to giving special care to children and showing value.

1. Ask each woman to find a partner and stand next to her.

2. Explain that the leader will call out actions and each pair must touch these

two body parts together.

3. For example, if the leader says, “Back to back” the partners must stand with

their backs touching. If the leader says, “Hip to Hip” each partner must stand with his or her hips touching. If the leader says, “Knees to Knees, each partner must stand touching the knees of their partner. However, if the

leader says, “People to People,” everyone must find a new partner.

4. Give many commands using different body parts.

5. Continue giving new commands using different body parts until the women are laughing and having fun.

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

2. Attendance and Troubleshooting

1. Promoter fills out attendance sheets for each Leader Mother.

1. Game: People to People – 10 Minutes

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2. Promoter asks if any of the Leader Mothers had problems meeting with their neighbors.

3. The Promoter helps to solve the problems that they mention.

4. Promoter thanks all of the Leader Mothers for their hard work and encourages them to continue.

5. Promoter asks the group’s Activity Leader4 to discuss the needed items for next week’s activity and solicit volunteers.

Visiting the Centre de Santé (Picture 1.1) – 10 Minutes

________________________________________________________________

3. Story

Read the story on page 4 of the flipchart.

Explain the two characters in the story: Karorero is the same woman that we

met in the last module. She is a Leader Mother and meets with her care groups each month. Barumwete is in one of the neighbor groups of Karorero. We will learn more about Barumwete and the challenges she faces in this

module.

The story encourages discussion about the difference between going to the Centre de Santé for treatment and going to the Centre de Santé for

preventative care.

Barumwete sees Karorero walking along the path. “Where are you going?”

Barumwete asks. “I am going to the Centre de Santé. I am pregnant and I want my baby and me to stay healthy.” Karorero says. Barumwete says, “Stay

healthy? You mean you are not sick? I thought that only sick people went to

the Centre de Santé.”

4. Ask

Read the questions on page 4 of the flipchart.

Ask the first questions to review the story.

Ask the second question to find out the beliefs of the women about preventative care.

Ask the last question to find out if the women in the group have visited the

Centre de Santé for antenatal care during this pregnancy.

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

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

pages.”

4 The Activity Leader should arrive ten minutes prior to each care group meeting to get

the description of the activity and the list of needed items from the promoter.

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? Where is Karorero going? Why?

? Why would a mother go to the Centre de Santé if she is

not sick?

? Have you visited the Centre de Santé during this

pregnancy? Why or why not?

Antenatal Care during Pregnancy (Picture 1.2) – 5 Minutes

________________________________________

5. Show:

Ask the caregivers to describe what they see in the pictures on page 7.

? What do you see in these pictures?

6. Explain:

Share the key messages using flipcharts pages 6 and 7.

Use the captions to remind you which images represent each point.

If you think you are pregnant, go to the Centre de Santé.

o If you feel movement inside, go to the Centre de Santé.

o If your monthly bleeding does not come, go to the Centre de Santé.

o Go meet with a health worker even if you are not sick.

o Health workers give vitamins to keep the mother and infant healthy during pregnancy.

Visit the Centre de Santé at least three times during pregnancy.

o After the health worker confirms your pregnancy, he will tell you

when to return.

o Usually women visit the health center once every three months.

o If the health worker sees problems, she will ask you to return more often.

o The health workers will examine the mother and give advice for a

healthy birth.

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Services provided by the Centre de Santé (Picture 1.3) – 5 Minutes

7. Show:



8. Explain:



The health worker measures the mother’s stomach to determine the size of the infant.

o If the infant is too small, he will give advice to help the infant grow.

The health worker gives vitamins and vaccinations.

o Vaccinations prevent tetanus (Rudadaza) for the mother and infant.

o Vitamins help the mother and infant stay healthy and strong.

The health worker treats sickness that can harm the mother and infant.

o He looks at the rims of the eyes for weak blood (anemia).

o He looks for swelling in the hands and face for a swelling sickness (toxemia).

o He draws a sample of blood to find sexually transmitted infections and HIV.

The health worker looks for problems that might cause a difficult birth.

o Poor position of the infant can put the mother at risk of death during delivery.

o The health worker will help the family plan for delivery at the

hospital or Centre de Santé.

Additional Information

Prenatal Vitamins

Recommended prenatal vitamins include folate and iron pills. Iron will be discussed in more detail in Lesson 3.

Folate helps to prevent low birth weight and neural tube defects (brain and spinal cord abnormalities). If the pregnant woman does not have enough

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folate, the infant’s brain and spinal cord are unable to fully develop. This often causes some form of paralysis to the infant.

Tetanus (Rudadaza) Immunization

If a pregnant mother is immunized against tetanus, her infant will also be

protected. The mother passes the antibodies (tetanus fighting cells) to the infant across the placenta (infant’s feeding bag).

Signs of Tetanus (Rudadaza)

Signs of tetanus in an infant include fever, inability to suck, crying that won’t stop, fast breathing, and stiffness of the body.

Toxemia (Preeclampsia)

Some swelling in pregnancy is normal especially of the legs and angles, but swelling of the hands and face may be a sign of toxemia. The causes of

toxemia are unknown. Its symptoms include high blood pressure, swelling of hands of hands and face and protein in the urine during pregnancy.

Preparing A Birth Plan (Picture 1.4) – 5 Minutes

________________________________________

9. Show:



10. Explain:



As the time of birth approaches, make a delivery plan.

Set aside money needed for transportation.

Ask someone to watch your children while you are away.

o Ask someone to prepare foods for the family.

Ask someone to help you during the delivery at the Centre de Santé.

o Ask them to stay with you during and after delivery.

Set aside clean clothes for you and the infant. Prepare food and water to eat

after delivery.

Why is it important to prepare for the delivery now?

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11. Activity: Make a Birth Plan – 15 Minutes

1. Review the last flipchart page of this lesson,” Planning for Birth at the Centre

de Santé.”

2. Ask if any of the mothers have already had children at the Centre de Santé.

Are there supplies that they needed that are not on the flipchart? Are there items on the flipchart that they did not need?

3. Ask each mother, “Do you have the supplies that you need for delivery?” If a mother does not have all of the supplies, ask her when she will purchase these supplies. Encourage every mother to take steps today to plan for

delivery.

4. Ask the group, “How much money is needed for transportation to the Centre

de Santé?”

5. Ask each mother, “Can you begin saving money for transportation?”

6. Ask each mother, “Who can you ask to care for your older children and

household while you are away for delivery?”

7. Discuss any questions they have about the birthing plan. Encourage those

who have not already made a plan to start today.

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

12. Probe – 10 Minutes

What do you think of these ideas? Is there anything that might prevent you

from following the practices we have discussed today?

Ask mothers to talk to a woman sitting next to them for the next five minutes.

They should share any personal concerns that they have with these practices. Together they should try to find solutions to these worries and problems. After five minutes, ask the Leader Mothers to share what they have discussed.

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13. Inform – 5 Minutes

Help find solutions to their concerns. Encourage them to try these new practices. If a woman offers a good solution to another woman’s concern, praise

her and encourage other mothers to consider using this solution when they talk with others.

14. Practice and Coaching – 20 Minutes

1. Ask Leader Mothers to share the teachings they have learned today using the first two flipchart pages. They should share with another woman in the care group using the ASPIRE method.

2. Tell the Leader Mothers listening to the message that they should give one

objection to the lesson; one reason that they think this message would be difficult for them.

3. The Leader Mothers sharing the message should try to help the women

overcome this obstacle.

4. After ten minutes, ask the women to switch roles.

5. The Promoter should watch, correct, and help the Leader Mothers who are having trouble.

6. When everyone is finished, answer any questions that the mothers have

about the materials, or today’s lesson.

15. Request – 2 Minutes

? Are you willing to commit to following the new practices that we discussed

today?

15

Ask mothers to give a verbal declaration that they will commit.

For example: I commit to discussing the birth plan with my spouse. I commit to visiting the Center de Santé once every three months for antenatal care. I

commit to visiting the Centre de Santé if I see signs that I am pregnant.

16. Examine ─ 15 Minutes

Ask each Mother one-on-one about her commitments.

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

commitment?

How – what did you do?

Finally ask each mother one on one about her practices in the last two weeks:

Have you tried any new health practices since our last meeting?

Do you believe that you can make healthy changes in your life?

Have you talked with other women in your group about making changes at home?

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Lesson 2: Maternal Nutrition

Pregnant women will eat an extra snack or extra meal each day for healthy growth of the infant during pregnancy.

o Caregivers will discuss importance of equal food distribution in the

family including adding extra food for women during pregnancy.

Pregnant women will eat a variety of foods with many different colors.

Every day, pregnant women will eat foods from each of the three food groups

including the protecting group (fruits and vegetables), the forming group (meat, dairy, beans, and nuts), and the energy group (grains, staple foods

and oils).5

o Pregnant women will discuss alternative foods that they can prepare and eat if normal family foods become unappetizing because of

nausea.

Pregnant women will avoid tobacco and alcohol use during pregnancy to

prevent having a low birth weight infant.

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

o Vaginal bleeding

o Severe headaches

o Severe stomach aches

o Persistent vomiting

Materials:


Lesson 2 Summary:

Game: Who is the Leader


Share the story and ask about current behaviors: Barumwete’s Difficult

Pregnancy

Show pictures and share key message on flipchart pages 14-19 about Increased Quantity and Variety of Foods, Three Food Groups, and Danger

Signs during Pregnancy.

Activity: Planning Healthy Meals



5 Diverse diet with many colors will help to increase the micronutrients in the diet:

phosphorus, potassium, magnesium, copper, zinc, magnesium, and iron (LDM). Objectives containing a black diamond were recommended messages based on the

Local Determinants of Malnutrition Study.

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Examine commitments and behaviors related to Antenatal visits and birth

planning.

1. Ask the Leader Mothers to sit in a circle. A volunteer leaves the room.

2. After the volunteer leaves, the group chooses a leader. The leader must

perform a series of actions, such as clapping, tapping a foot, or snapping their fingers. Everyone in the group copies the action of the leader.

3. The volunteer returns and stands in the middle of the circle. It is the task of the volunteer to find the secret leader. The leader must change the actions

without being caught. The group protects the leader by not looking at her.

4. Secretly, the leader of the group begins an action as she had done a few

minutes ago. The others follow the leader doing the action with her. After a few seconds, she changes the action to something new. As soon as the

others see, they should do repeat the same action that the leader is doing.

5. When the volunteer spots the leader, the volunteer joins the circle, and the

person who was the leader leaves the room.

6. Repeat the game several times.

? What can we learn about life from this game?

Sometimes the person who is making decisions is hidden.

Often when we meet with women in their home, there are others in the

family that lead or influence their decisions.

We need to share messages with women, but also help them to pass these same messages to the leaders in their home.

Now, let’s begin the lesson.


1. Game: Who is the Leader – 10 Minutes

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5. Promoter asks the group’s Activity Leader6 to discuss the needed items for

next week’s activity and solicit volunteers.

Barumwete’s Pregnancy (Picture 2.1) – 10 Minutes

3. Story


The story tells us the Barumwete is having a difficult pregnancy. When we

look at the images we see that one of the problems is that the food in unequally distributed in her home.

Barumwete is also pregnant. This pregnancy has been difficult. She works long

hours in the field, but is often tired. She is unable to finish her work. Barumwete eats the same foods each day, but does not gain weight. She knows her infant is not growing well. She is afraid that her infant is suffering.

4. Ask:


Ask the first two questions allowing the mothers to guess what is causing her

weakness, and inability to gain weight. Barumwete should rest during her pregnancy and try to work less than she did when she was not pregnant.

She also needs to eat a greater variety of foods, and more than normal.

Ask the last question to find out if the women believe that pregnant women need to change the way they eat or work when pregnant.

Encourage discussion. Don’t correct “wrong answers.” Let everyone

give an opinion. This page is for discussion, not for teaching.


pages.”



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? Why is Barumwete’s pregnancy difficult?

? What is causing these difficulties?

? Have you changed the way that you eat and work since

you became pregnant? How?

Increased Quantity and Variety of Foods (Picture 2.2) – 5 Minutes

5. Show:



6. Explain:



Eat one extra meal or snack each day.

o Extra food gives energy to pregnant women.

o Extra food helps the infant to grow.

o If you are breastfeeding another child, add two extra meals or

snacks each day.

o Continue breastfeeding until the new baby comes.

As soon as you know you are pregnant, eat more food than normal.

o The man in this picture wants his wife to be healthy so he makes sure she eats extra food while pregnant.

Rest often during pregnancy. Reduce your workload.

o Divide your work with others in the family.

o Take breaks in between your work to sit and rest.

Do not smoke or drink alcohol during pregnancy.

o Tobacco and alcohol increase the risk of infants being born weak and small.

Additional Information for the Trainer

Tobacco and Alcohol

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A study in the U.S. showed that the risk of infant low birth weight increased by 26% for every five cigarettes smoked per day. Similar findings have been

found for drinking three of more glasses of alcohol per day. For more information, see: http://aje.oxfordjournals.org/cgi/content/abstract/121/6/843

The Three Food Groups (Picture 2.3) – 5 Minutes

7. Show:



8. Explain:



o There are three food groups: Body building, energy, and protecting.

Body building foods make strong bones and muscles.

o Eat meats and fish.

o Eat milk foods like milk, and yoghurt.

o Eat eggs.

o Eat beans, peanuts, and seeds.

Energy foods give energy and power for our daily work.

o Eat oils like palm oil, animal fat, and butter.

o Eat roots like manioc, taro, and potatoes.

o Eat cereals like maize and rice.

o Eat sugars like honey and sugar cane.

Protecting foods keep away illness.

o Eat vegetables like cabbage, green eggplant, and leaves.

o Eat fruits like plantains, avocado, guava, papaya, and mangoes.

Every day, eat foods from the three food groups.

o Add small amounts of these foods to your family meals.

o Eat one food from each group each day.

http://aje.oxfordjournals.org/cgi/content/abstract/121/6/843

21

? What are some family foods that you eat each day? Do they include at least

one food from each group?

? Are there any foods that you do not eat on this chart? Why don’t you eat

them?


Taboos

Some people believe that liver causes women and infants to lose their teeth; this is not true. Liver is the best source of iron and a food for body building.

Some people believe that milk and avocado cause infants to grow “too large.” Milk and avocado have high fat content and may increase weight gain.

However, if eaten in small quantities each week, it is very beneficial to a woman’s health. If too much weight gain is seen, mothers can substitute

another food in the food group for the milk or avocado as desired.

Danger Signs During Pregnancy (Picture 2.4) – 5 Minutes

9. Show:

Ask the caregivers to describe what they see in the pictures on page 19 of

the flipchart.


10. Explain:

Ask the caregivers to describe what they see in the pictures on page 19 of

the flipchart.

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If you see any of the following danger signs, go to the Centre de Santé.

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

o Don’t wait to see if you feel better.

o Go immediately to the Centre de Santé for treatment.

Vaginal bleeding

Severe headaches

o Severe headaches and swelling of the face and hands are signs that your

pregnancy is in danger.

Severe stomach aches

Vomiting that won’t stop


Preeclampsia (toxemia)

See Lesson 1 for more information on toxemia.

11. Activity: Planning Healthy Meals – 15 Minutes

1. Ask each woman to choose a partner in the group.

2. Ask them to discuss the foods that they usually prepare for the family.

3. Encourage them to consider how to add foods of different colors, and foods from each food group to their family foods. Ask them to discuss “extra”

foods or snacks they can eat each day during pregnancy.

4. Ask each woman to choose one or two new foods to add to her family foods each week, and one extra snack to increase the amount of foods that eat

each day.

5. After 10 minutes, ask the women to share their ideas with the large group.

6. Encourage discussion.


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What do you think of these ideas? Is there anything that might prevent you from following the practices we have discussed today?

Ask mothers to talk to a woman sitting next to them for the next five minutes. They should share any personal concerns that they have with these practices.

Together they should try to find solutions to these worries and problems. After five minutes, ask the Leader Mothers to share what they have discussed.


Help find solutions to their concerns. Encourage them to try these new practices. If a woman offers a good solution to another woman’s concern, praise her and encourage other mothers to consider using this solution when they talk

with others.

14. Practicing and Coaching – 20 Minutes

1. Ask Leader Mothers to share the teachings they have learned today using the first two flipchart pages. They should share with another woman in the care group using the ASPIRE method.

2. Tell the Leader Mothers listening to the message that they should give one

objection to the lesson; one reason that they think this message would be difficult for them.





6. When everyone is finished, answer any questions that the mothers have

about the materials, or today’s lesson.

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15. Request – 2 Minutes


today?


For example: I commit eating at least one food from each food group each day. I commit to eating more food than normal during pregnancy. I commit to adding foods of many different colors to family foods. I commit to talking with

my spouse about adding new foods to our family foods.



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

? How? What did you do?


Have you talked with someone about going with you to the Centre de Santé

to deliver your infant? Have you talked with someone about watching your household while you are

away at the Centre de Santé during delivery? Have you visited the Center de Santé in the last three months for antenatal

care? When will you go again?

25

Lesson 3: Micronutrients (Iron and Iodine)

Caregivers will be able to describe how iron helps to strengthen mothers and infants for a healthy delivery and birth.

o When there is enough iron in the body, the mother and infant will be

strong during delivery and birth.

o If the mother has anemia (weak blood), the mother is at greater risk of

death because of a prolonged delivery and increased blood loss.

o If the infant has anemia (weak blood), the infant may be born too early, too small or dead.

Pregnant women will take iron supplements (vitamins) during pregnancy to prevent anemia.

Pregnant women will eat foods rich in iron each day including beans, lentils,

green leafy vegetables, and organ meats.

o Liver is the best food that a woman can eat to increase iron.

Caregivers will be able to identify the signs of weak blood and seek help at

the health center.

o The inside lids of the eyes, the nail beds, and tongue appear pale (or lack blood) when iron is low.

o Some adults and children have the desire to eat dirt when their body is

low in iron. This desire is a warning that the body needs more iron.

Pregnant women will avoid eating foods at meals that decrease iron absorption, such as tea, cocoa, coffee, and caffeinated drinks.

Caregivers will be able to describe how iodine helps to strengthen mothers

and infants for a healthy delivery and birth.

o Iodine helps the growing infant’s brain to develop. Too little iodine hurts the brain making it difficult for children to work well in school.

o Too little iodine leads to infant death during pregnancy (miscarriage).

Pregnant woman will add a sprinkle of iodized salt to their food each day while pregnant or breastfeeding.

Materials:


2. Package of Iodized Salt*

3. Container of Iron Pills*

Lesson 3 Summary:

Game: Stand Next to Someone


Share the story and ask about current behaviors: Barumwete Feels Dizzy

26

Show pictures and share key message on flipchart pages 22-26 about Benefits of Iron and Signs of Deficiency, Increase Iron with Foods and

Vitamins, and Benefits of Iodine and Signs of Deficiency.

Activity: Checking Symptoms





Examine commitments and behaviors related to maternal nutrition.

1. Ask the women to stand up and slowly walk.

2. Explain that the facilitator will call out a type of clothing (or characteristic)

and the women should rush to stand next to someone wearing that clothing.

3. For example, the facilitator might say, “Find someone wearing red. » The women will rush to stand by someone wearing red. A person wearing red will

stand still waiting for the others to gather around her.

4. Then the facilitator tells the women to begin walking again. Then she gives

another command, such as, « find someone wearing earrings. » A person wearing earrings will stand still waiting for the others to gather around her.

5. Continue giving commands, and encouraging the women to walk in between each command.

6. Try giving commands related to previous lessons, such as, “find someone

who has visited an antenatal clinic” or “find someone who shows equal value to their children”

7. Give others in the group and opportunity to lead the game.





1. Game: Stand Next to Someone - 10 Minutes

27




Barumwete Feels Dizzy (Picture 3.1) – 10 Minutes

3. Story


The story discusses the signs of low iron (anemia). Barumwete has not been eating well and continues to have a difficult pregnancy.

Karorero walks past Barumwete’s house and sees Barumwete sitting on the

ground. “What is wrong?” Karorero asks. Barumwete says she became dizzy and had to sit down. Karorero sees that Barumwete’s skin and nails are pale. She is breathing fast.

4. Ask


Ask the first two questions to allow the women to guess the cause of Barumwete’s illness.

Ask the last question to find how the women would treat this illness.


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

? What is wrong with Barumwete?

? What is the cause of this illness?

? What can Barumwete do to overcome this illness?



28

Benefits of Iron and Signs of Deficiency (Picture 3.2) – 5 Minutes

5. Show:



6. Explain:

Ask the caregivers to describe what they see in the pictures on pages 22 and 23.

Mothers with low iron are weak and have difficulty giving birth.

o Iron is a nutrient inside certain foods.

o Low iron makes it hard to work for long hours.

o Low iron may cause fast breathing and a fast heartbeat.

o Many mothers with low iron die during childbirth.

Iron gives energy and helps the mother to work hard.

o Iron keeps the mother’s and infant’s blood strong.

o Iron gives the mother energy to push.

Pale lips, eyelids, and nails are a sign of low iron.

o Strong blood is bright red.

o When blood is weak, it loses color.

Wanting to eat dirt is a sign of low iron.

o This is a sign that the body needs more iron.

o Talk to a health worker about taking iron vitamins.


Iron

During pregnancy, the amount of blood in your body increases by 50%.

Iron is needed to carry oxygen in the blood to your body organs and the placenta which feeds the infant in the belly.

Anemia (Iron Deficiency)

Iron deficiency may be caused by lack of iron-rich foods, but can also be a result of blood loss during menstruation, parasites (hookworm) and malaria.

Women with severe anemia are 3.5 times more likely to die during pregnancy and childbirth than women without anemia.

Prevalence

29

According to UNICEF, fifty percent of pregnant women and 40-50% of children under age five in developing countries are iron deficient.

Consequences

Iron deficient mothers are more likely to birth premature babies, low-birth

weight infants who suffer from infections, weakened immunity, learning disabilities, impaired physical development and in severe cases, death.

Increase Iron with Foods and Supplements (Picture 3.3) – 5

Minutes

7. Show:



8. Explain:



Eat foods high in iron to prevent weak blood and problems during delivery.

o Eat beans and lentils each day.

o Eat green leaves each day.

o Eat organ meats like kidney, heart, or liver once each week.

o Liver is the best food that a woman can eat to increase iron.

Avoid drinking tea and coffee with meals.

o These drinks take iron out of the foods that you eat.

o If you must drink them, wait at least one hour after you have finished eating.

Take iron vitamins during pregnancy to prevent weak blood and problems

during delivery.

o Take iron pills throughout your pregnancy to keep your blood and your infant’s blood strong.

Take iron pills daily with food.

o Drink lots of water and eat lots of fruits, vegetables, beans,

and peanuts to avoid constipation.

30


Iron Pills

Iron pills (also referred to as ferrous sulfate) or prenatal vitamins should be

available to pregnant and lactating women at health centers.

Women should take iron pills daily, with food after their first prenatal visit until delivery, if possible.

Side Effects

Many women experience side effects when taking iron pills. Side effects include stomach upset, heartburn, and constipation. To ensure women are

able to continue taking iron pills, explain the importance of taking the pills with food, preferably at breakfast or lunch.

Drinking lots of water and eating foods high in fiber help prevent side effects.

High fiber foods include: beans, peanuts, fruits, and vegetables.

If women are unable to take the prescribed dose of iron pills because of discomfort, have them start slowly, cutting the pills in ½ or taking them

every other day until they can take the prescribed dose.

Benefits of Iodine and Signs of Deficiency (Picture 3.4) – iminota

5

9. Show:



10. Explain:



31

A child born with enough iodine will do well in school.

o Iodine is a nutrient in certain foods.

o Iodine helps the infant’s brain to grow well.

Too little iodine in a woman’s body can cause infant death.

o The infant’s brain and body may stop growing causing the infant to

die.

A lump on the neck is a sign of too little iodine.

o Even if a pregnant woman does not have a lump, she needs to add iodine to her foods.

Add a sprinkle of iodized salt to family foods each day.

o Pregnant women need more iodine than other women.

o Iodized salt is the best way to increase iodine.


Iodized Salt

Since 1990, 34 countries have adopted regulations that mandate that all salt for human and livestock consumption must be iodized.

Iodine Deficiency

According to UNICEF statistics in 2008, 98% of Burundian households consumed adequately iodized salt.

Iodine is a mineral which is essential for the development and growth of the

human body.

Iodine deficiency is the most common preventable cause of mental disability in the world. The most serious form of mental retardation from Iodine

deficiency is cretinism. Over 20 million people around the world suffer varying degrees of mental deficiency caused by a lack of iodine.

Iodine deficiency disorders can cause problem pregnancies that result in miscarriages, stillbirths, and low birth weight infants who have lower rates of

survival.

Symptoms of Iodine Deficiency

Goiter and hypothyroidism (too little iodine) are the signs of iodine deficiency. Hypothyroidism is difficult to diagnosis without blood tests because the signs can be attributed to many causes. Signs of

hypothyroidism are feeling tired, depressed, dry skin, feeling colder than usual, and constipation.

11. Activity: Checking Symptoms – 15 Minutes

32

1. Show the women the package of iodized salt. Explain what they should look for on the package.

2. Show the women a bottle of iron pills. Explain where to find them and how often to take them.

3. Next, ask the women in the group to look at each other’s throats. Are there women in the group who have an enlarged neck? Have they been to the clinic to ask about iodine?

4. Ask the group, “How many of you add iodized salt to your foods each day?” Ask these women to share with the group how they use iodized salt.

5. Ask the women in the group to look at each others’ tongues, and the insides of the lips and eyelids. Examine the nails.

6. Find the women with the reddest tongues, and insides of the lip and eyelid.

Find the women with the palest tongues and insides of the lips and eyelids.

7. Ask them about the different foods that they eat each day.

8. Ask the group: What can we learn from the foods that are mentioned by the women with the reddest tongues? Are they eating certain foods that the others should try also?

9. Ask how many of the women have received iron vitamins from the health clinic.

10.Use the positive examples to encourage those who are not yet using iodized salt or iron vitamins and foods.



Saba abo bavyeyi bayagishe umugore yicaye i ruhande rwabo. Ni bavugane nawe amakenga yabo yose boba bafise ku cigwa. Bari hamwe bakwiye

kugerageza gutora umuti w’ayo makenga n’izo ngorane. Imitota itanu iheze, uce usaba Abakenyezi Ndongozi bashikirize ivyo bayazeko.


33



14. Practice and Coaching ─ 20 Minutes

1. Ask Leader Mothers to share the teachings they have learned today using the

first two flipchart pages. They should share with another woman in the care group using the ASPIRE method.

2. Tell the Leader Mothers listening to the message that they should give one objection to the lesson; one reason that they think this message would be

difficult for them.

3. The Leader Mothers sharing the message should try to help the women overcome this obstacle.


5. The Promoter should watch, correct, and help the Leader Mothers who are

having trouble.

6. When everyone is finished, answer any questions that the mothers have about the materials, or today’s lesson.

15. Request ─ 2 Minutes


today?


For example: I commit to adding iodized salt to my foods each day. I commit to getting iron pills from the antenatal clinic this week. I commit to adding foods rich in iron to my family foods each week.

34



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

? How – what did you do?


Did you eat foods from each of the three food groups yesterday? Which

foods did you eat?

Did you eat an extra snack or meal yesterday?

What were the colors of the foods that you ate yesterday?

Have you talked with your spouse about changing the foods that you eat?

35

Lesson 4: Hand Washing with Soap (or Ash)

Caregivers will wash their hands with soap and water at the appropriate times:

o Those helping with delivery will wash their hands before delivery.

o Before handling a newborn baby.

o After throwing child’s feces or other waste into a latrine

o After using the latrine or cleaning child feces or urine.

o Before preparing foods, feeding children or eating.

Caregivers will wash their hands appropriately:

o Wet hands and soap with water.

o Rub hands with soap until a lather forms.

o Rub in between fingers and under fingernails for 30 seconds while singing the hand washing song.

o Rinse off the soap with running or dripping water.

o Allow hands to air dry or dry them with a clean cloth.

Caregivers will encourage family members to wash hands after using the

toilet, before touching food, eating or preparing meals, or handling a newborn baby.

Caregivers will be able to sing the Hand Washing Song.

Caregivers will believe they have the tools, information and ability to care for and protect the health of their child (increased self efficacy).

Materials:


2. Basin, water and soap, or Tippy Tap for hand washing*

Lesson 4 Summary:

Game: Rainstorm


Share the story and ask about current behaviors: The Family has Diarrhea

Show pictures and share key message on flipchart pages 30-35 about Soap Kills Germs, When to Wash, and How to Wash.

Activity: The Hand Washing Song





36

Examine commitments and behaviors related to iron and iodine.

1. Ask the women to sit quietly in a circle with their eyes closed.

2. Their job is to listen to the sounds made by the woman sitting on their left side. They should repeat the sound that they hear from the woman sitting on

their left.

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

rain.

4. The woman to her right makes this sound, and then the next woman until

everyone in the circle is rubbing their palms together.

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

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

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

8. Then the facilitator slaps her thighs and the group joins in one by one.

9. Then the facilitator stomps her feet, the rain becomes a hurricane.

10.To indicate the storm is stopping, the facilitator reverses the order, thigh

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

Now that we are energized, let’s take attendance and discuss last weeks’ lesson.



2. Promoter asks if any of the Leader Mothers had problems meeting with their

neighbors.



1. Game: Rainstorm - 10 Minutes

37


The Family Has Diarrhea (Picture 4.1) – 10 Minutes

3. Story


The story explains how Barumwete’s family became sick. It introduces the topic of germs causing sickness.

Barumwete’s son walked out of the latrine. When Barumwete wasn’t looking, he

took some of the family food with his hand. When they all sat down to eat, they dipped their hands into one bowl of water to wash. They didn’t use soap. Barumwete stirred the food and served everyone. That night the family had

stomach pains and diarrhea. Soon they were all running to the latrine.

4. Ask


Ask the first question to discuss the causes of sickness.

Ask the last two questions to discover the current hand washing practices of the women in the group.




pages.”

? Why did everyone have stomach pains and diarrhea?

? When should you wash your hands?

? When did you wash your hands today?

Soap Kills Germs (Picture 4.2) – 5 Minutes

5. Show:




38


6. Explain:



Germs live all around us.

o Germs are tiny creatures that cause sickness.

o Germs live on our skin, in our house, on plants and trees.

o Germs are too small to see with our eyes.

o In this picture, a special glass shows us the germs that live on our hands. The germs in this picture are green.

Many germs enter the body on our hands.

o Germs get inside the body when we lick our fingers.

o Germs that land on our hands get into our mouth when we eat.

Germs that get inside the body cause coughing and diarrhea.

o Germs that get inside the body cause most sicknesses.

Soap kills germs! If you don’t have soap, use ash.

o Washing hands with soap or ash prevents diarrhea and sickness.

o Washing hands with soap and ash protects pregnant mothers from illness that may harm their infant.

Additional Information for the Trainer:

Diarrheal Disease

Hand washing with soap is the most cost-effective intervention to prevent death and disease from diarrhea.9 Hand washing before eating, preparing

food and after using the toilet can reduce diarrhea in children by 50 percent.10

Definitions

A germ is a bacteria or virus that causes disease.

Effectiveness

Manufactured soap and water is the best and most effective virus and

bacteria killer. If manufactured soap is not available, homemade soap and

ashes are the best substitutions.

9 Cairncross, S. Valdmanis V. 2006. Water Supply, Sanitation and Hygiene Promotion. Chapter 41. Disease

Control Priorities in Developing Countries. Second Edition. Edt. Jameson et al 2006. The World Bank. Washington DC: National Institutes of Health. 10 Curtis, V., and S. Cairncross. 2003. “Effect of Washing Hands with Soap on Diarrhea Risk in the

Community: A Systematic Review.” Lancet Infectious Diseases 3: 275–81.

39

When to Wash (Picture 4.3) – 5 Minutes

7. Show:



8. Explain:



Wash your hands with soap or ash before preparing food.

Wash your hands with soap or ash before eating.

o Help your children to wash their hands.

Wash your hands with soap or ash after using a latrine.

Wash your hands with soap or ash after cleaning a child’s bottom.

o Wash your children's hands frequently.

o Encourage your family to wash hands with soap and water at these

times too.

Wash hands with soap or ash before helping with delivery.

o Ask the person who has agreed to help you deliver to wash hands before delivery.

Wash hands with soap or ash before holding a newborn.

o Newborns get sick very easily.

o Keep them healthy by keeping your hands clean.

o Ask others to wash hands before touching the infant.

What are some other times it is important to wash hands?


Newborns and Hand washing

40

A study showed that newborns where birth attendants and mothers washed

hands before handling them had a 41% lower illness rate compared to newborns where the mother and birth attendant did not wash hands.11

How to Wash (Picture 4.4) – 5 Minutes

9. Show:



10. Explain:



Encourage the women that hand washing is easy to do, but it is very effective in killing germs. We can stop infection in our homes with this simple practice.

Wet your hands and the soap with water.

o If you are using ash, wet hands, then add ash.

Rub your hands and fingers together.

o As you rub your hands, the soap will lather.

o Begin singing the Hand Washing Song.

Rub between your fingers. Lather up to your wrist.

Rub under your fingernails.

o Continue rubbing your hands together until the Hand Washing

Song is finished.

Pour clean water over your hands to rinse off the soap.

o Never wash and rinse hands in one basin.

o The water will hold the germs and spread them to everyone else who dips their hands in the water.

o If washing in a basin, use a cup to pour water over your hands.

It is best to let your hands air dry.

o If you use a towel, clean the towel every day.

o A wet towel can easily gather germs and put them back onto your

hands.

11 Rhee V. et al. 2008. “Maternal and birth Attendant Hand Washing and Neonatal Mortality in Southern

Nepal.” Archives of Pediatrics & Adolescent Medicine. Vol 162 (No. 7), pp 603-608. July 2008

41


Germs on Towels

Germs grow and multiply quickly on damp surfaces and fabrics. Avoid using towels to dry hands unless they are washed each day.

Hang the towel on a tree limb or rack in the sun after each use. The sunlight

and heat from the sun kills the bacteria and virus as the towel dries.

11. Activity: The Hand Washing Song – 15

Minutes

Song Example:

I wash his hands before he eats, I wash his hands after visiting the latrine

I wash after changing diapers, I wash before preparing food. - Chorus

I rub between my fingers, I rub under my fingernails

I rinse with clean water, and let the air dry my hands. - Chorus

Chorus:

Hand washing keeps my child healthy. I wash with soap.

I wash with ash. I wash a long time. I wash because I love my child.

1. Practice the Hand Washing Song with the Leader Mothers.

2. Explain: In order to kill all the germs, hands need to be washed for at least

30 seconds. To help us remember to wash our hands for 30 seconds we will sing this song.

3. Each person in your home should learn the song and sing it after they wet

their hands and begin to scrub their hands.

4. When the song is finished, it is time to stop scrubbing and rinse.




42




Bafashe kuronka umuti w’amadidane yabo. Ni haba hari umugore yishuye neza impungenge z’uwundi mugore, ni umushimire kandi uhimirize abandi bagore ngo bazirikane umuti yashikirije.


5. Ask Leader Mothers to share the teachings they have learned today using the

first two flipchart pages. They should share with another woman in the care group using the ASPIRE method.

6. Tell the Leader Mothers listening to the message that they should give one objection to the lesson; one reason that they think this message would be difficult for them.




10.When everyone is finished, answer any questions that the mothers have about the materials, or today’s lesson.


43


today?


For example: I commit to washing my hands with soap before handling my newborn. I commit to talking with my family about washing hands at the

appropriate times. I commit to teaching my family how to wash their hands using the Hand Washing Song.



What was your commitment at the last lesson?

Have you kept that commitment? How – what did you do?


Did you add iodized salt to your family foods yesterday?

Did you take an iron pill yesterday?

What foods did you eat yesterday that were high in iron?

44

Lesson 5: Creation of Household Hand washing

Stations

Each caregiver will make a Tippy Tap and hang it near the latrine.

Each caregiver will be able to instruct others in the creation of a Tippy Tap.

Each caregiver will know how to set up a hand washing station using basins.

o Never rinse and wash hands in the same basin. Always use a cup to pour water over the hands for wetting hands and for rinsing hands.

Materials:


2. Encourage each family to gather Tippy Tap materials in preparation for this

lesson.

a. Two branches (1½ meter long) with Y-shaped ends

b. two sticks (one meter long)

c. string (1 meter long and another ½ meter long)

d. soap and a small plastic tub

e. a large nail

f. a candle

g. 5 liter container

h. hand saw

i. shovel

j. rocks

Lesson 5 Summary:

Game: Germ in the Circle


Share the story and ask about current behaviors: Too Difficult to Wash

Show pictures and share key message on flipchart pages 38-43 about Tippy Tap Supplies, Tippy Tap Construction, Hanging the Tippy Tap, and Using the Hand washing Station.

Activity: Practice Using the Tippy Tap





Examine commitments and behaviors related to Hand Washing.

45

1. Ask the women to stand in a circle. Choose a volunteer to stand in the middle of the circle.

2. Cover the volunteer’s eyes with a piece of cloth. After the volunteer’s eyes are covered, ask everyone in the circle to move to a new place.

3. Explain: The circle is a compound. The volunteer in the middle is a diarrhea-

causing germ. The women in the circle must try to walk through the compound without touching the germ.

4. The game begins when “the germ” calls out two women’s names from the group.

5. These two women must quietly change places with each other, while keeping away from “the germ.” “The germ” tries to touch the players as they pass by

listening and reaching out for them. All of the other players must remain quiet.

6. If someone is tagged, they become “the germ” and the game is repeated.

7. Repeat the game so that everyone has a chance to play.





neighbors.







1. Game: Germ in the Circle - 10 Minutes

46

Too Difficult to Wash (Picture 5.1) – 10 Minutes

3. Story


The story discusses the difficulty that Barumwete has trying to adopt the new

hand washing practice.

Use the story to encourage the women, that change is not always easy. Sometimes we need to rearrange objects in our homes to make change easier.

Barumwete heard the messages from Karorero. She committed to wash her hands every day just like Karorero taught her. But when she left the latrine, she forgot. When she started to prepare foods, the soap was missing. When the

family sat down for dinner, there was no water left. She wanted to change, but the change seemed too difficult.

4. Ask


Ask the first question to review Barumwete’s difficulties.

Ask the second question to discuss the challenges that the women face trying

to wash hands in their own homes.

Ask the last question to discover how many women have hand washing stations.


give an opinion. This page is for discussion, not for teaching. After the participants answer the last question, move to the next flipchart

page by saying, “Let compare your ideas with the messages on the following pages.”

? Why didn’t Barumwete wash her hands?

? Is it easy for you to wash your hands?

? Do you have a hand washing place (station) with soap

and water? Where is it?

Tippy Tap Supplies (Picture 5.2) – 5 Minutes

5. Show:

47



6. Explain:

Every time this lesson is taught a Tippy Tap is made. Mother leaders should also make Tippy Taps when teaching Mother Beneficiaries.

Tippy Taps are made from free, locally available materials (like gourds or

discarded plastic containers) but can also be made from purchased containers.



While you are sharing, demonstrate each step.

A Tippy Tap makes hand washing easy and uses a small amount of water.

o It uses less water than hand washing with water basins.

Let’s make one together. You need:

Two branches (1 ½ meter long) with Y-shaped ends, two sticks (1 meter long), string (1 meter long and another ½ meter long), soap and a small

plastic tub, a large nail, a candle, 5 liter container, hand saw, shovel and rocks.

o Rinse and clean the 5 liter container well.

o Do not use pesticide containers for the Tippy Tap.

o The pesticide will damage your hands and cause sickness.


Tippy Tap Adaptations

Hand washing station can be adapted using locally available materials. For more ideas, visit the following website:

http://www.schoolsanitation.org/BasicPrinciples/HandwashingFacilities.html

Tippy Tap Construction (Picture 5.3) – 5 Minutes

7. Show:


http://www.schoolsanitation.org/BasicPrinciples/HandwashingFacilities.html

48


8. Explain:



Attach the long string (1 meter long) to the end of one stick.

Make a mark with the nail on the side of the container. Mark it 1 and 1/2

finger’s length down from the lid.

o The exact measurement is 12 centimeters.

Heat the point of the nail over a candle. Make a hole in the container with the hot nail.

o Put the hole where you have marked the container.

o This hole is where the water will come out to wash hands.

Heat the nail again. Make a hole in the center of the lid.

Thread the string (attached to the stick) through the hole in the lid. Tie a knot at the end of the string.

o Screw the lid back onto the five liter container.

o The knot should not be able to pass through the hole.

Use the nail to make a hole in the soap and the center of the tub.

o Use a plastic tub or metal tin. o The tub will protect the soap from rain.

Hanging the Tippy Tap (Picture 5.4) – 5 Minutes

9. Show:



49

10. Explain:



Thread the short string through the tub and tie a knot.

o Make sure that you still have space for the soap on the string.

Thread the string through the soap and tie a knot.

o The tin can is like an umbrella to protect the soap from the rain.

o When you hold up the string, the tin should rest on the knot and not slide down. Make the knot under the soap large so the soap does not

fall off the string.

Plant the Y-shaped branches in the ground next to the latrine. Hang the stick and container on top.

o Thread the handle of the container through the stick.

When you stand on the stick, the container should tip over. Adjust the string if it

does not work.

Tie the soap string on the stick next to the container. Add rocks under the Tippy Tap.

o Puddles encourage mosquitoes to come lay eggs.

o The rocks prevent puddles from forming.

o Fill the Tippy Tap with water up to the hole on the side.

11. Activity: Practice using the Tippy Tap – 15

Minutes

1. Ask each woman in the group to wash her hands using the Tippy Tap and the Hand Washing song.

2. Follow the pattern below:

a. Put your foot on the stick, tipping the Tippy Tap container.

b. The water will begin to trickle out of the hole.

c. Wet your hands and the soap.

d. Take your foot off the stick to stop the water.

e. Begin singing the Hand Washing song rubbing your hands and under

your nails and up to your wrists.

f. When the song is finished, put your foot on the stick, tipping the Tippy

Tap container.

g. Use the water from the hole to rinse your hands.

3.

50

4. If you are in someone’s home, ask each member of the family to wash their hands using the Tippy Tap.

5. Answer questions and encourage them to use the Tippy Tap after using the latrine, before eating, before preparing food, or handling a newborn.










1. Ask Leader Mothers to share the teachings they have learned today using the first two flipchart pages. They should share with another woman in the care

group using the ASPIRE method.

2. Tell the Leader Mothers listening to the message that they should give one objection to the lesson; one reason that they think this message would be

difficult for them.

51







today?


For example: I commit to using my Tippy Tap after using the latrine, before eating, before preparing food, or handling a newborn. I commit to helping other

build a Tippy Tap. I commit to setting up another hand washing station inside the house. I commit to keeping water and soap at the Tippy Tap.



? What was your commitment at the last lesson?

? Have you kept that commitment? How – what did you do?


When did you wash your hands yesterday?

Did you share the hand washing messages with the others in your family?

When did your children wash their hands yesterday?

Can you sing the Hand Washing Song?

53

Lesson 6: Malaria Prevention

Caregivers will be able to explain the transmission of the malaria parasite.

o A person with malaria is bitten by the mosquito who takes some of

their infected blood. The mosquito infects everyone else that he bites.

Caregivers will be able to describe the impact of malaria on pregnant women, and those with HIV.

Malaria infection in pregnancy causes severe anemia (weak blood) which may lead maternal death before or after birth.

o Babies of mothers who had malaria during pregnancy are more likely to be born too early, too small, or dead.

o HIV infected pregnant women are at higher risk of contracting malaria.

Pregnant women will sleep under a mosquito net each night to reduce the number of mosquito bites.

Caregivers will ensure that children less than five years of age sleep under a mosquito net each night to reduce the number of mosquito bites.

Caregivers will properly hang insecticide treated mosquito nets in their house to reduce the number of mosquitoes.

All family members will sleep under a bed net each night to prevent malaria.

Caregivers will fill puddles with rocks and pebbles, removing standing water in old buckets, tires, and cans.

o Bury or burn trash that traps water.

o Dig drainage rows to disperse pools of standing water.

Caregivers will believe that have the confidence, time and skills needed to prevent malaria (increased self efficacy).

Caregivers will believe that they have the ability to stop mosquitoes (and the parasites they carry) from harming those who are most vulnerable to

malaria.

Materials:


2. Bring two different types of mosquito nets that are commonly found in the market.

Lesson 6 Summary:

Game: The Two Mosquitoes


Share the story and ask about current behaviors: Barumwete’s Fever

54

Show pictures and share key message on flipchart pages 48-53 about Malaria and Transmission, Malaria Risks in Pregnancy, and Malaria Prevention.

Activity: Hanging a Mosquito Net





Examine commitments and behaviors related to using the Tippy Tap.

1. Ask the women to stand in a circle. The facilitator stands with them.

2. There are two mosquitoes in this game. One mosquito makes this noise “Zzzz” and the other mosquito makes this noise “Eeee.”

3. Ask the women to practice saying each mosquito sound.

4. When the facilitator says, “Zzzz” everyone must stand on their toes and flap

their arms like wings (elbows out). Encourage the women to practice.

5. When the facilitator says “Eeee,” everyone must stand still, balancing on one leg with arms at their sides. Encourage the women to practice.

6. The object of the game is to do the right action at the right time!

7. The facilitator should say “Zzzz” and “Eeee” many times. Say “Zzzz” two or

three times in a row to see if the women continue doing the right action.

8. Continue giving several women a chance to be the facilitator.

Now that we are energized, let’s begin.




neighbors.



1. Game: The Two Mosquitoes - 10 Minutes

55


Barumwete’s Fever (Picture 6.1) – 10 Minutes

3. Story

Read the story on page 44 of the flipchart. In the story, the neighbor’s infant died because of malaria. Barumwete did

not believe the fever was serious. However, she was wrong.

Barumwete began pounding grain with her neighbor early in the morning. The

neighbor was not pounding very well. “What is wrong?” Barumwete asks. “I have fever today. I don’t have much strength,” says her neighbor. “Many people have fever. Tomorrow you will feel better,” says Barumwete. The

neighbor was sick in bed for many days. Soon Barumwete saw a small grave behind the house. The infant had died inside the mother’s body after the illness.

It died in the mother’s belly and was born dead.

4. Ask

Read the questions on page 44 of the flipchart. Ask the first two questions to discover the women’s beliefs about fever.

Ask the last question to find out if the women believe that malaria is a serious illness for pregnant women.


After the participants answer the last question, move to the next flipchart

page by saying, “Let compare your ideas with the messages on the following pages.”

? What did her neighbor say about fever? Is this true?

? What is the cause of a fever?

? Is fever dangerous for pregnant women?

Malaria Defined and Transmission (Picture 6.2) – 5 Minutes



56

5. Show:



6. Explain:



Fever is the most common sign of malaria.

o Fever is not a sickness, but a sign that there is sickness in the

body.

Mosquitoes carry the sickness of malaria.

o Mosquitoes that carry malaria come out when the sun is low in the sky and at night.

In this picture, the mosquito bites the neighbor with malaria. The mosquito then bites Barumwete’s son.

o When the mosquito bites a person who already has malaria, he

picks up the illness.

o The mosquito gives malaria to each person that he bites.

Now Barumwete’s son has malaria.

o If one person in the community has malaria, everyone is at risk

of getting malaria from a mosquito bite.

o The fewer people with malaria, the fewer cases of malaria.

Additional Information for the Trainer:

Anopheles mosquitoes

Malaria is carried only by the Anopheles mosquito. Anopheles can be

identified by the way they carry their back legs up in the air.

Some mosquitoes are active during the day. Anopheles mosquitoes are most

active at dusk, dawn and during the night.

Transmission

When the Anopheles bites an infected person, they take a small amount of

blood which contains tiny malaria parasites.

About one week later, when the mosquito takes its next blood meal, these parasites mix with the mosquito's saliva and are injected into the person

being bitten.

57

Seven to 30 days after the Anopheles’ bite (the incubation period), the first

symptoms appear. Incubation periods are shorter for the malaria parasite falciparum and longer for the malaria parasite.

Malaria Risks in Pregnancy (Picture 6.3) – 5 Minutes

7. Show:



8. Ask:

Shikiriza inyigisho nyamukuru ukoresheje impapuro za 48 na 49 z’igitabo c’amasanamu mfashanyigisho.

Ukoreshe amungane ndondozi magufi yanditseko kugira ngo wiyibutse

isanamu ijana na buri ngingo.

Malaria makes the mother’s blood weak.

o Weak blood (anemia) is very dangerous in pregnancy.

o HIV infected mothers are more likely to get severe malaria.

Weak blood starves the infant of food.

o The infant in her belly gets food from the mother’s blood.

o If her blood is weak, it does not provide enough food to the infant.

Weak blood causes the infant to be born too early, too small, or dead.

Weak blood increases the risk of dying in childbirth.

o Anemia makes the mother very weak and tired.

o If she is tired, labor takes longer.

o She loses more blood in a long labor and may not survive.


Child Death

For children under five years of age (worldwide), malaria is the fourth largest cause of death. One out of every three children (under age five) who become ill with malaria will die.

Immunity

58

Many adults get malaria. Some have malaria several times a year without

serious illness. They have developed some immunity (resistance) against the sickness and may become ill, but will rarely die. Their body has seen the

parasite before and has made an internal medicine to combat the sickness.

Pregnancy reduces the immunity of women increasing the risk for severe illness.

Infants have little or no immunity and are at high risk of severe malaria and death.

Malaria in Pregnancy

Malaria is the cause of 10% of all maternal deaths and 60% of stillbirths.

Anemia

Women with severe anemia are 3.5 times more likely to die during pregnancy

and childbirth than women without anemia.

Malaria Prevention (Picture 6.4) – 5 Minutes

9. Show:



10. Explain:



59

Hang an ITN in your house to kill mosquitoes. Tie it up during the day.

o The insecticide on the net kills mosquitoes that land on the net.

o Loosely tie the net during the day so children do not play in it.

Sleep under an ITN each night.

o An ITN prevents bites from mosquitoes that enter the house at

night.

o ITNs prevent malaria and weak blood in pregnancy.

o Encourage everyone in the family to sleep under a net to prevent infection.

Mosquitoes lay eggs is water. Empty buckets, cups, and cans. Store

them upside down.

o Put lids on buckets to keep our rain water and insects.

Bury or burn trash, tires, and cans that trap water.

o If fewer mosquitoes are born, there will be fewer mosquitoes to carry malaria.


Insect Breeding

Mosquitoes and black files breed in small puddles of standing water. This is

why it is important to prevent water puddles under dish racks and Tippy Taps.

Mosquitoes can carry many diseases such as malaria, filariasis, and yellow

fever. Black flies can carry river blindness.

Untreated Nets

Some mosquito nets are not treated with insecticide. They don’t kill

mosquitoes but still protect the family from bites. If ITNs are not available, an untreated net is recommended.

Preventing Malaria is a Community Effort

The more families that use ITNs, treat malaria promptly and prevent

mosquitoes breeding sites, the fewer mosquitoes will exist to spread malaria.

Preventing malaria is a community wide effort. Everyone family must do

their part.

11. Activity: Hanging a Mosquito Net – 15 Minutes

60

1. Show the women the different types of malaria nets available from the local market.

2. Demonstrate how to hang the net in the home. a. Use the ties to connect to the ceiling or wall with nails, hooks, or wire.

b. It should be hung so the person inside has room to move freely without hitting the net.

c. Leave about 20 cm to tuck under the sleeping mat so that those inside

are completely enclosed. d. If hanging the net for yourself, leave one corner of the net untucked so

that you can easily enter the net when climbing into bed. Once you enter the net, carefully lift the sleeping mat, and tuck the remaining corner of the net underneath. To exit, lift the corner of your sleeping

mat, untuck the net, and crawl out. 2. Discuss ways they can add more nails, hooks or wire inside the home to hang

the net. 3. If people sleep outside, discuss ways to hang the net so that the person is

completely enclosed and has room to move freely.

4. Demonstrate how to hang the net during the day. a. To avoid rips and tears by children or others walking by the net, tie it

into a loose knot or toss the bottom of the net over one of the ties so that it is off the ground and out of reach of small children.

b. Reinforce the importance of leaving the net hanging during the day. Even mosquitoes that land on an ITN will be killed by the repellent.

5. Untie the nets, and let the women in the group practice hanging the nets.

Continue until everyone has a turn.






61



Ask mothers to talk to a woman sitting next to them for the next five minutes.

They should share any personal concerns that they have with these practices. Together they should try to find solutions to these worries and problems. After

five minutes, ask the Leader Mothers to share what they have discussed.

14. Practice and Coaching ─ 20 Millions










today?


62

For example: I will sleep under an ITN each night. I will go to the clinic at the first sign of fever. I will turn over buckets, cans, or things that collect water in

my compound.






Do you have a hand washing station in your house?

Does your hand washing station have soap and water?

When did you wash your hands yesterday?

63

Lesson 7: Preparing For Delivery and Birth

Leave for the Centre de Santé immediately if one or more of the danger signs is seen.

o When contractions are strong and come regularly every 20 minutes.

o Water comes from the vagina as if a bag of water has broken inside.

o Bloody and sticky discharge comes from the vagina.

Caregivers will be able to describe the process of delivery.

o The contractions begin to open the cervix.

o After the cervix is open to 10 centimeters, the mother begins pushing,

taking strong breaths and pushing with all her strength.

o When the infant’s head stays (and does not retract into the womb

between pushes) then the mother should make take short breaths (small pushes) so the head will come out slowly.

o After the head and the front shoulder, the body of the infant will come quickly.

o Tie and cut the umbilical cord after the pulsating has stopped (1-3 minutes).

o When the cord lengthens from the vagina, the health worker will ask

the mother to push out the placenta.

Caregivers will not push on the outside of the pregnant woman’s body to

make the baby come out faster.

Caregivers will not give medicine or put anything in the woman’s vagina to hurry labor and delivery.

Caregivers will be able to list at least four advantages of birthing at a Centre

de Santé (hospital or clinic).

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

o Sterile and clean environment for birthing

o Ability to give vaccinations (BCG and Polio) to infants at birth

Materials:


Lesson 7 Summary:

Game: Musical Chairs


Share the story and ask about current behaviors: Breaking Waters

64

Show pictures and share key message on flipchart pages 56-60 about Signs that Birth is Near, Delivery at the Centre de Santé, and Final Stages of

Delivery.

Activity: Advantages of Delivering at the Centre de Santé





Examine commitments and behaviors related to malaria prevention.

1. Ask the women to stand in a circle with something to sit on (a chair or a mat

behind them). The facilitator stands to the side.

2. Now remove one of the chairs (or mats) so that one person does not have a

place to sit.

3. Tell the women that you are going to sing a song. The women will walk

around the circle clapping and dancing as you sing. When you stop singing, they must find the closest seat (mat or chair) and sit down. The woman who

doesn’t find a seat must leave the circle.

4. The facilitator should turn his back (so he can’t see the women) and begin

singing. Stop suddenly in the middle of the song. The woman without a seat leaves the game.

5. Remove one more chair (or mat). Then begin the song again with the remaining women.

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




1. Game: Musical Chairs - 10 Minutes

65





Breaking Waters (Picture 7.1) – 10 Minutes

3. Story


The story explains all the things that Barumwete has prepared for delivery

and introduces the signs of labor.

Barumwete has decided to have her birth at the health center. She has prepared her supplies, put together food and water for after delivery, and talked with the neighbors about her plans. She is on her way to the market when a

gush of water comes out of her. What is this? Is this a sign of labor?

4. Ask


Ask the first two questions to discover the women’s beliefs about labor.

Ask the last question to find out if the women know when it is time to leave

for the Centre de Santé.



pages.”

? What happens to Barumwete? What does it mean?

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

sign?

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

center?



66

Signs that Birth is Near (Picture 7.2) – 5 Minutes

5. Show:



6. Explain:



Pains in the belly that are frequent, strong, and regular.

o Pains will start slowly.

o Pains will increase in number, strength, and length as time passes. These pains begin to open the bag that holds the infant.

Clear water comes out of the vagina.

o The infant is inside a bag of liquid in the mother’s belly.

o The bag may break, leaking out the clear liquid.

o It may break before the pains begins or any time during the

pains.

Clear or pink-colored mucus comes out of the vagina.

o When the neck of the bag opens, the lid of the bag comes out of the vagina.

o The lid is made of clear or pink mucus. There may also be some blood.

These are signs that birth is near. Go immediately to the Centre de Santé.

o Do not give medicine or put anything in the woman’s vagina to hurry the birth.

Delivery at the Centre de Santé (Picture 7.3) – 5 Minutes

7. Show:


67


8. Explain:



When the bag inside the vagina is open, take long, deep breaths.

o The health worker will tell you when it is time to start pushing.

o It may take from sun up to sun down for the bag to open completely.

o Pushing helps the infant’s head to come out of the bag.

o Never push on the outside of the woman’s body to make the infant

come out.

When the top of the head appears and stays in the opening, take quick, slow breaths.

o This helps the head come slowly.

o If the mother pushes hard and fast, the vagina may tear.

o The head usually comes out face down.

The health worker guides the head so the shoulder comes out next.

o The infant’s body will come quickly after the front shoulder.

After birth, quickly dry the infant’s head and body.

o Wipe the mucus from the nose and mouth.

o Keep the infant on the same level as the mother until the cord is cut.

o Dry the head and hair.

Additional Information for the trainer

Contractions

It may take 10 to 20 hours for contractions to open the cervix during the first pregnancy. For a second or third birth, it may only take 7 to 10 hours.

The cervix is considered open when it dilates 10 centimeters.

Final Stages of Delivery (Picture 7.4) – 5 Minutes

________________________________________

9. Show:


68


10. Explain:



When the cord stops beating, tie it in two places.

o The beating should stop moments after you finish drying the

infant. The cord will turn white.

o Tie it two finger-widths away from the infant.

o Add another tie two finger-widths away.

Cut the cord with a clean razor in between the two ties.

Place the naked infant onto the mother’s naked chest and let him

breastfeed. Cover them with a warm blanket.

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

When the cord lengthens, the mother pushes out the infant’s feeding bag (placenta).

o Never pull on the cord. It may break inside.

o The nurse will tell you when to push.

o The feeding bag has fed the infant while he was in the belly.


Delayed Clamping

Delayed clamping (after the cord turns white) of the umbilical cord lessens the risk of anemia in newborns.

Placenta

As the placenta separates from the womb, the cord will slowly come out of the vagina. This is a sign that the placenta has separated and the woman

can begin pushing to help the placenta exit.

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

Breastfeeding

Encourage immediate breastfeeding. This will be discussed in detail in the next lesson.

69

11. Activity: Advantages of Delivery at the Centre de Santé – 15 Minutes

1. Ask the mothers to compare birth at home to birth at the Centre de Santé.

2. Draw two columns on the ground. Above one column, draw an outline of a house. Above the second column, draw an outline of a clinic (or cross for

Centre de Santé).

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

4. Some advantages for birthing at the health center might include:

a. There are specialists to help me if I have trouble.

b. It is a clean environment for birthing.

c. They can give the infant care immediately after birth if there is a problem.

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

5. Compare the advantages of birth at home versus birth at the health center. Which of these choices is best for the infant? Which of these choices is best

for the mother?

6. Reinforce that birth at the Centre de Santé is the safest place for both infant and mother. If there are problems, the health workers can work quickly and

help the mother and infant recover. At home, if there are problems, the mother and infant are at higher risk of infection and death.

7. Discuss their concerns. Reinforce the advantages of birthing at the Centre de Santé. Encourage those who are not yet committed to birth at the health

center to reconsider and discuss the idea with their family.





70















today?


71

For example: I commit to going to the health clinic when I see the signs that birth is near.



? What was your commitment at the last lesson?

? Have you kept that commitment? How – what did you do?


Did you sleep under a mosquito net last night?

Is there a mosquito net hanging in your home right now?

Did you look for breeding sites around your house? What did you do to keep mosquitoes from coming?

72

Lesson 8: Immediate Breastfeeding at Birth and

Use of Colostrum

Caregivers will lay the newborn infant immediately on the mother’s chest after birth.

o Keep the infant on the mother’s chest with skin to skin contact for at

least two hours after birth to help maintain the infant’s body temperature and form a bond between mother and infant.

o Interacting with the newborn infant helps the mother’s breasts to develop milk more quickly.

Mothers will begin breastfeeding within one hour after birth so that infants receive the first yellow milk (colostrum).

o Colostrum (the first yellow milk) protects infants from illness. It is like

a vitamin and vaccine that makes the infant strong.

o Colostrum helps to clean the infant’s stomach (to expel the first dark

stool).

o The infant’s sucking on the breast after birth stimulates the mother’s

breast to begin producing all the milk your baby needs in its first days

and months of life.

o Immediate breastfeeding makes the placenta come out faster and decreases mothers’ bleeding after delivery.

o Putting a newborn infant to the breast teaches the infant how to suck

before he is hungry (LDM).

Caregivers will give only breast milk to infants less than six months of age;

never giving water, beer or other foods to before six months.

Caregivers will share these messages with family and those attending the birth so that the child will be put to the breast immediately after delivery.

Materials:


2. Three rocks, eggs or balls that match the size of the balls in the activity.*

Lesson 8 Summary:

Game: I’m Going to Have a Baby


Share the story and ask about current behaviors: Barumwete’s Delivery

Objectives containing a black diamond were recommended messages based on the

Local Determinants of Malnutrition Study.

73

Show pictures and share key message on flipchart pages 84-89 about Skin to Skin Contact, Immediate Breastfeeding, and Importance of the First Yellow

Milk.

Activity: Belly Balls





Examine commitments and behaviors related to Delivery at the Centre de

Santé.

1. This is a game of memory. The women in your group must remember

everything that the other women in the group say and repeat it.

2. Ask the women to sit or stand in a circle with the facilitator.

3. The facilitator begins by saying, »I’m going to have a baby at the Centre de

Santé and I’m bringing (and adding something they will bring). »

4. There are no wrong answers in this game. The women can bring any item

they want to bring. The important part is for the women to try to remember the other items listed by the other mothers.

5. For example, « I’m going to have a baby at the Centre de Santé and I’m bringing clean cloth.”

6. The woman to the facilitator’s right must repeat the phrase and add another

item. For example, « I’m going to have a baby at the Centre de Santé and I’m bringing clean cloth and some sugar cane. »

7. Continue with each woman in the circle adding a new item to the list.

8. If a woman forgets or says the items in the wrong order, she must leave the circle.

9. When there is only one woman in the circle the game is over.

Now let’s begin today’s lesson.


1. Game: I’m Going to Have a Baby - 10 Minutes

74







Barumwete’s Delivery (Picture 8.1) – 10 Minutes

3. Story


The story explains the conflict that Barumwete had with her Mother-in-Law

after the birth of the infant.

Barumwete went to the Center de Centre with her mother-in-law. The delivery

was long a difficult. Barumwete named him Mvuyekure. After the baby’s cord was cut, the health worker went to put him on Barumwete’s chest. However,

the Mother in Law disagreed. “Barumwete has been weak and sick. Her breast milk is not even ready yet. Let me take the infant.” Barumwete is upset. She does not agree.

4. Ask


Ask the first and second question to review the story.

Ask the last question to discover the current practices of the women immediately following birth.



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



75

? What happened after the delivery?

? Why did the Mother-in-Law take the infant away?

? What do you do with an infant right after birth? Why?

Skin to Skin Contact (Picture 8.2) – 5 Minutes

5. Show:



6. Explain:



After the infant is dried, place him skin to skin on the mother’s chest.

o This helps the infant bond with the mother.

o The mother’s body keeps the child warm.

o Keep the infant with skin to skin contact for several hours after birth.

Put the infant to the mother’s breast to help the placenta come out. Do this

within the first hour after birth.

o Breastfeeding helps the mother’s milk to come.

o Breastfeeding helps to stop the mother’s bleeding.

o Breastfeeding helps the placenta to come out faster.

? How can we prevent conflict (like Barumwete’s conflict) after birth?

? Have you shared the teachings that you have learned with the person

coming with you to the delivery?

76


Infant Heat Loss

Newborns are not able to maintain their body temperature as well as adults. They lose body heat quickly if they are wet, uncovered, or exposed to drafts.

In the first 1-2 minutes, the newborn may lose enough heat for his body temperature to fall 2 °C.

Twenty five percent of an infant’s heat loss comes from the head. Cover the infant’s head with a hat or cloth to keep them warm.

Immediate Breastfeeding (Picture 8.3) – 5 Minutes

6. Show:

Ask the caregivers to describe what they see in the pictures on page 67 of the flipchart.


8. Explain:



Start breastfeeding within one hour after birth.

o The yellow milk should be the first taste for the infant.

o Immediate breastfeeding helps the infant to learn how to feed before he is hungry.

An infant needs only breast milk; never give water, beer, bottles, or other

foods or liquids to infants less than six months of age.

o Infant bottles carry germs and cause sickness.

o Breast milk is the best food and drink for the infant.

When the infant takes the first yellow milk often, it helps the white milk to come sooner.

o The infants sucking makes the mother’s breasts produce white milk.

Importance of Colostrum (Picture 8.4) – 5 Minutes

77

9. Show:



10. Explain:



The first yellow milk protects infants from illness.

o The first yellow milk contains vitamins and vaccines from the

mother to protect the infant.

o Infants who drink the yellow milk are healthier than infants who do not drink the yellow milk.

The first yellow milk cleans the infant’s stomach.

o The yellow milk helps the child expel the first dark, sticky feces.

o The first feces come within the first two days after birth.

11. Activity: Belly Balls – 15 Minutes

1. Find small rocks, eggs or other objects that are the same size as the balls

shown in the picture.

2. Ask the women in the group.

How big is an infant’s stomach when the child is born?

3. Explain: At birth, a newborn’s stomach is only the size of a knuckle on one of your fingers, or this small rock

(show the rock which represents Jour 1).

78

Do you think a mother has enough yellow milk to fill a stomach this size? (The answer is yes.)

4. Explain: A mother may worry that she does not have enough yellow milk at birth for the newborn. However, a newborn’s stomach is the size of this

small ball. The mother can easily fill it with her yellow milk. She must give the yellow milk often so the infant can fill and refill his stomach throughout

the day.

How big is an infant’s stomach when the child is three days old?

5. Explain: At three days old, the infant’s stomach is the size of this small rock

(use the rock which represents Jour 3).

Do you think a mother has enough yellow milk on the third day to fill a stomach this size?” (The correct answer is yes.)

6. Explain : A mother needs to feed aninfant often. This is because the

stomach is very small. An infant needs frequent feedings to fill the stomach and then time to rest so the body can digest the foods.

How big is an infant’s stomach when the child is 10 days old ?

7. On the 10th day of life, the infant’s stomach is the size of a this rock (show the rock which represents Jour 10). By the 10th day the mother has a lot more milk. However she still needs to feed the infant often to fill the infant’s

stomach and let them rest to digest.

8. Answer questions. Pass the rocks around so all the mothers can see.





79





1. Saba aba Mères Leaders gushikiriza abandi inyigisho baronkejwe uyu musi bakoresheje impapuro zibiri za mbere zo mu gitabo c’amasanamu. Bakwiye

kubwira uwundi mugore ari muri Groupe de Soins bakoresheje bwa buryo ASPIRE. (Change to first two flipchart pages of this lesson)

2. Bwira abo ba Mères Leaders bumviriza ubwo butumwa ko borondera ikintu batemera muri ubwo butumwa; imvo imwe ituma babona ko iyo nyigisho yoba igoye kuri bo.

3. Abo ba Mères Leaders bashikiriza izo nyigisho bakwiye kugerageza gufasha abo bagore gutsinda izo ntambamyi.

4. Iminota cumi iheze, usabe abo bagore kuguza ibibanza. Uwo wundi mu Mère Leader nawe azoca atanga inyigisho ziri mu mpapuro zibiri zikurikira zo mu

gitabo c’amasanamu. Change to first two flipchart pages of this lesson)

5. Umu Promoteur akwiye kwumviriza, agakosora, kandi agafasha aba Mères leaers vyagoye.

6. Bose bahejeje, ace yishura ibibazo abo bavyeyi boba bafise ku bijanye n’ibikoresho, canke n’icigwa c’uyu musi.

15. Request ─ Minutes 2

80


today?


For example: I commit to talk with the person coming with me to delivery about skin to skin contact and immediate breastfeeding. I commit to giving the first yellow milk to my infant immediately after birth. I commit to breastfeeding my

infant and not giving any other foods or drinks.






Have you talked with your spouse about delivering at the Centre de Santé?

Have you prepared the supplies you need to deliver at the Centre de Santé?

Have you completed your birth plan?

81

Lesson 9: Newborn Care Practices

Caregivers will wash the newborn appropriately:

o Wait until 24 hours have passed after birth before using water to clean the newborn.

o After the first day of life, use a wet cloth to clean the infant each day.

o Wait until the cord falls off and the skin has healed before washing the infant in a basin of water.

o Clean the baby’s eyes by wiping each one with a cloth starting at the nose and wiping outward.

o Wash the infant’s face and neck daily with a wet cloth washing and drying inside the folds of skin.

Caregivers will keep the cord clean and dry to prevent infection.

o Cover the umbilical cord with clean cloth.

o Do not put medication or herbs on the cord.

o If urine or feces touches the cord, wash it with soap and water and dry it with a clean cloth.

Caregivers will keep the newborn warm especially in the first three weeks of life.

Caregivers will wash their hands with soap and water before and after

handling the baby especially after cleaning the child’s bottom.

Mothers will breastfeed the infant on demand whenever the infant shows signs of hunger.

Newborns will receive the first two vaccinations that they need at birth to

prevent polio and BCG.

Caregivers will take the newborn immediately to the Centre de Santé if any of the following newborn danger signs are seen:

o Difficulty feeding or refusing to eat

o Feeds less than ever 5 hours

o Pus coming from the eyes

o Irritated cord with pus or blood

o Yellow eyes or skin

Lesson 9 Summary:

Game: Germs and Soap


Share the story and ask about current behaviors: No Beer for Biguvu

Show pictures and share key message on flipchart pages 72-77 about

Keeping the newborn clean, Newborn Care, and Newborn Danger Signs.

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Activity: Preventing Newborn Death





Examine commitments and behaviors related to signs the birth is near and

delivery at the Centre de Santé.

1. Ask the women to stand in a circle.

2. Tell each woman to look around and silently choose another woman in the

group. Ask them to raise a hand when they have chosen someone.

3. When everyone has chosen, explain that the person they selected represents a germ. They should try to stay as far away as they can from this person.

4. Tell each woman to look around and silently choose another woman in the group. Ask them to raise a hand when they have chosen someone.

5. When everyone has chosen, explain that the second person they selected represents a bar of soap to prevent infection from the germ. They should try

to stand as close as possible to the soap so they will be protected from the germ.

6. Make sure that everyone understands what they should do and then begin the game.

7. After several minutes, reverse the game. Tell them that the first person represents the soap and the second person represents the germ.

8. After several minutes when everyone is laughing, stop the game.

Now, let’s begin our lesson.




neighbors.

1. Game: Germs and Soap – 10 Minutes

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No Beer for Biguvu (Picture 9.1) – 10 Minutes

3. Story


In this story, Karorero’s husband is defending the new health practices that he and his wife are trying with their newborn child.

Karorero’s husband is confident of the health teachings because he has tried

them and seen the difference in the infant’s life.

Karorero gave birth to a son. They named him Biguvu. Karorero’s husband is talking with his neighbor. The neighbor laughs saying, “Why are you refusing to give beer to the child?” Karorero’s husband responds, “We gave Biguvu special

yellow milk which already cleaned his stomach. We can already see he is healthier than his older siblings were at birth.”

4. Ask


Ask the first question to review the story and hear the opinions of the women

about Karorero’s husband’s actions.

Ask the last question to discover the special care that the women in the group give to an infant in the first week of life.




pages.”

? What did the neighbor laugh at Karorero’s husband?

? Why is Karorero’s husband confident that breast milk is

best for the infant?

? What special care do you give your infant in the first

week of life?



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Washing the Newborn (Picture 9.2) – 5 Minutes

5. Show:



6. Explain:

Share the key messages using flipchart pages 72 and 73.


Do not clean the newborn with water on the first day.

o Do not wash with a wet cloth until one full day has passed.

o Newborns have trouble keeping their body warm.

On the second day, wash the infant’s head, neck and around the eyes. Do

this each day.

o Use a wet cloth starting on the second day.

o Wash inside the folds of skin on neck and legs.

o Clean the infant quickly so their body does not get cold. o Wrap the rest of the body in a blanket to keep the infant warm.

Keep the cord clean and dry. Do not put medication or plants on the cord.

o If urine or feces touches the cord, wash it with soap and water.

o Dry it with a clean cloth.

o It will heal best if it stays dry.

After the cord falls off, wash the infant in a basin each day.

o The cord should fall off in 5 to 10 days.


Infant Mortality

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

seven days after birth. There are three main causes of newborn death: infections, asphyxia (where infant does not receive enough oxygen before, during, or just after birth), and preterm births.

In Burundi 41 babies out of every 1,000 live births die in the first four weeks of birth.

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The first week and month of the newborn’s life are a time of great risk. Although the risk of death decreases as time passes, every newborn needs

careful attention during the first month of life.

Newborn Care (Picture 9.3) – 5 Minutes

7. Show:



8. Explain:



Ask the health worker to immunize your newborn against child diseases.

o Newborns should receive two treatments.

o The first are drops put into the infant’s mouth.

o The second is a needle that the health worker will inject into the newborn.

o These treatments protect the infant from sickness.

Dress the infant in warm clothes and a hat if the child is cold.

o An infant needs more clothing than an adult.

o Add extra clothing especially during the first three weeks.

Breastfeed when the infant shows signs that he is hungry: moves his tongue in and out, makes sucking noises, sucks on his fingers, turns his

head from side to side, or cries.

Newborn Danger Signs (Picture 9.4) – 5 Minutes

9. Show:


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10. Explain:



The infant has fever.

The infant has trouble breathing.

The infant has difficulty feeding or refuses to feed.

The infant has fits of convulsions.

Pus comes from the infant’s eyes.

The infant has yellow eyes and yellow skin.

Blood or pus comes from the (umbilical) cord.

o Pus and blood are signs that germs have infected the cord.

Take the newborn immediately to the Centre de Santé if you see any of these danger signs.

11. Activity: Preventing Newborn Death – 15 Minutes

1. The first seven days of an infant’s life is the time when he is most vulnerable

to germs, sickness, and death. Many children die in the first seven days of life. Let’s look at the reasons that newborns die.

2. Ask 10 women to stand up. These 10 women represent 10 newborns that

have died in the first seven days of life.

a. Ask three of the 10 women to stand together. These three women

represent newborns that died because they were born too small or too early.

b. Ask two of the remaining 7 women to stand together. These two

women represent newborns that died because the delivery was very hard and the infants did not receive enough oxygen before, during, or

after delivery.

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

gotten inside their bodies).

d. The last three women represent newborns that have died for many

different reasons. Each one was different.

3. Ask, are you surprised by the reasons that children die? Why or why not?

4. Spend the next five minutes encouraging the women to discuss practices to

prevent the three main causes of newborn death.

5. Add any of the following practices that were not mentioned.

6. To prevent infants born too small or too early.

a. Eat well during pregnancy

b. Visit the antenatal clinic to monitor the size of the infant.

c. Take prenatal vitamins including iron and folate.

d. Sleep under a mosquito net (to prevent weak blood).

e. Use iodized salt.

7. To prevent infants not receiving enough oxygen.

a. Visit the antenatal clinic to monitor the position of the infant (if a child

is breech or the labor too long many infants lose oxygen).

b. Deliver at a Centre de Santé so health workers can make sure the

labor and delivery are not too long.

8. To prevent newborn infections.

a. Wash your hands before handling a newborn.

b. Keep the umbilical cord clean.

c. Use a clean razor to cut the umbilical cord.

d. Deliver at the Centre de Santé where health workers can immediately treat infections.



Ask mothers to talk to a woman sitting next to them for the next five minutes. They should share any personal concerns that they have with these practices. Together they should try to find solutions to these worries and problems. After

five minutes, ask the Leader Mothers to share what they have discussed.

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today?

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For example: I commit to waiting one day before using water to clean my newborn. I commit to washing the face and neck of my newborn each day

starting on day 2. I commit to taking my newborn to the health center if I see a danger sign. I commit to making sure my newborn receives vaccinations at birth.






Have you talked with the person coming with you to delivery about skin to

skin contact and immediate breastfeeding?

Have you talked with your family about the importance of the first yellow milk?

What will you feed your infant in the first days of life?

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Lessons 1-9 Pre and Posttest

Ibibazo bibiri bijanye na buri cigwa bishikirijwe ngaho musi. Imbere n’inyuma yo kwigisha ibi vyigwa ku bakozi no ku bigisha, tanga akabazo ko guherezako kugira ngo urabe urugero batahuyeko. Ku baronse ibice 75% canke batabikwije

(boba bafise n’iburiburi inyishu icenda z’ukuri), ongera ubahe izindi nyigisho kugira ngo ubafashe gutahura ivyigishijwe. Abigisha nabo ntibogerageza

kwigisha abandi mu gihe nabo nyene boba batarashobora kuronka 75% canke kubirenza.

1. How many times should a pregnant mother visit the Centre de Santé

for antenatal care?

e. She should visit the Centre de Santé only when she feels sick.

f. She should visit the Centre de Santé every month.

g. She should visit the Centre de Santé once every three months.

h. She should go the Centre de Santé for antenatal care one day before delivery.

2. Four things should be included in the caregiver’s birth plan. Choose

the item below that is NOT part of the birth plan.

a. Save money for transportation to the Centre de Santé

b. Arrange for someone to care for children in the home while the mother is away.

c. Arrange for someone to prepare food for the children and take care of other household tasks.

d. Purchase infant bottles and pans for boiling water.

3. Which of the following foods should a pregnant woman avoid?

a. Smoking tobacco or drinks containing alcohol

b. Foods high in iron such as liver or organ meats.

c. Foods containing iodized salt.

d. Foods containing many different colors.

4. True or False? __________ At the first sign of pregnancy, a woman

should eat an extra snack or meal each day.

5. If a mother has low iron, what should she do?

a. Add iodized salt to her diet.

b. Eat more beans, leafy vegetables, and organ meats.

c. Eat more fruits like mango, banana, and papaya.

d. Eat more breads, oils, and dairy.

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6. How much salt does a woman need to eat each day to increase iodine?

a. A small sprinkle in foods each day.

b. Two spoonfuls each day.

c. A small sprinkle in a meal once each week.

d. Two spoonfuls every other day.

7. What are the words to the Hand Washing song?

________________________________________________________________

__________________________________________________________________________________________________________________________

8. Name THREE of the FIVE most important times that a person should

wash their hands.

________________________________

________________________________

________________________________

9. True or False? __________ A family should wash and rinse their hands in one water basin before eating.

10. Where is the best place to hang a Tippy Tap?

__________________

11. How is malaria transmitted?

a. Mosquitoes pick up malaria from drinking bad water. They carry the bad water to others.

b. Malaria is transmitted by drinking dirty water.

c. Malaria is transmitted from eating bad foods.

d. Mosquitoes pick up malaria when they bite a person with malaria.

They carry the sickness to others they bite.

12. Name two things a pregnant woman can do to prevent malaria.

___________________________________________________________

____________________________________________________________

13. Name two signs of labor (the birth of the child is near). These signs tell the mother she should leave quickly for the Centre de Santé.

_________________________________________________________

_________________________________________________________

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14. When should the umbilical cord be cut?

a. As soon as the infant is delivered.

b. After the cord stops pulsing and turns white.

c. Before the mother begins breastfeeding

d. After the placenta (infant’s feeding bag) is delivered.

15. Which of the following practices is NOT recommended in the first hours of life?

a. Give water to the infant to drink.

b. Place the infant skin to skin on the mother’s chest.

c. Encourage the mother to breastfeed to help the placenta come out.

d. Breastfeed the infant giving the first yellow milk.

16. True of False. ___________ The first yellow milk helps the child to expel the first dark feces.

17. On what day can you use a wet cloth to wash a newborn?

a. On the first day

b. On the second day

c. On the third day when the white milk comes

d. On the 10th day when the umbilical cord falls off.

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

_____________________________________________

_______________________________________________

________________________________________

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Lesson 1-9 Pre and Posttest ANSWERS

1. How many times should a pregnant mother visit the Centre de Santé for antenatal care?

C. She should visit the Centre de Santé once every three months.

2. Four things should be included in the caregiver’s birth plan. Choose the item below that is NOT part of the birth plan.

D. Purchase infant bottles and pans for boiling water.

3. Which of the following foods should a pregnant woman avoid?

A. Smoking tobacco or drinks containing alcohol

4. True or False? _TRUE__ At the first sign of pregnancy, a woman should

eat an extra snack or meal each day.

5. If a mother has low iron, what should she do?

B. Eat more beans, leafy vegetables and organ meats.

6. How much salt does a woman need to eat each day to increase

iodine?

A. A small sprinkle in foods each day.

7. What are the words to the Hand Washing song?

Dr. D. Please add the Kirundi words to the song here. ________________________________________________________________

__________________________________________________________________________________________________________________________

8. Name THREE of the FIVE most important times that a person should wash their hands.

Any three of the following are correct:

Wash hands before eating

Wash hands after using the latrine_ (or throwing away child feces)

Wash hand before preparing (or touching) food

Wash hands of child after they use the latrine

Wash hands of a child before they eat or touch food

9. True or False? ___FALSE__ A family should wash and rinse their hands

in one water basin before eating.

10. Where is the best place to hang a Tippy Tap? __Near a Latrine____

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11. How is malaria transmitted?

D. Mosquitoes pick up malaria when they bite a person with malaria. They carry

the sickness to others they bite.

12. Name two things a pregnant woman can do to prevent malaria.

Any two of the following are correct:

Sleep under a mosquito net each night.

Hang a mosquito net in the house each day.

Fill puddles with rocks.

Empty cans, tires, and buckets with standing water.

13. Name two signs of labor (the birth of the child is near). These signs tell the mother she should leave quickly for the Centre de Santé.


Waters breaking from the vagina

Contractions that are strong, regular and close together.

Mucus comes from the vagina

14. When should the umbilical cord be cut?

B. After the cord stops pulsing and turns white.

15. Which of the following practices is NOT recommended in the first hours of life?

A. Give water to the infant to drink.

16. True of False. _TRUE_ The first yellow milk helps the child to expel

the first dark feces.

17. On what day can you use a wet cloth to wash a newborn?

B. On the first day

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


He moves his tongue in and out and makes sucking noises.

He sucks on his fingers.

He opens his mouth and turns his head from side to side.

He cries.

Essential Nutrition, Hygiene, and Care Practices during...

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