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

Module 1: Orientation and Essential Nutrition Actions during Pregnancy and

BreastfeedingLesson Plan

Orientation and Essential Nutrition Actions during Pregnancy and Breastfeeding

Contents

Lesson 1: Introduction to the Program...................................................................7Lesson 2: CHA and VCHW Teaching Methods......................................................16Lesson 3: Nutrition and Care during Pregnancy and Breastfeeding.....................29Lesson 4: Anemia Prevention...............................................................................40Lesson 5: Immediate Breastfeeding....................................................................48Lesson 6: Exclusive Breastfeeding from Birth to Six Months...............................56Lesson 7: Encouraging Mothers to Breastfeed.....................................................64Lessons 1-7 Pre and Posttest...............................................................................71Lessons 1-7 Pre and Posttest ANSWERS..............................................................74

Lessons, stories, and activities in the Orientation and Essential Nutrition Actions during Pregnancy and Breastfeeding Flipchart are explained in detail in this lesson plan.

Understanding the Lesson Plan

Each lesson begins with objectives. These are the behavior, knowledge and belief objectives that are covered in the lesson.

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. Some lesson objectives are related to behavioral determinants.

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

1 In the DFAP, studies were completed on hand washing and complementary feeding. See http://barrieranalysis.fhi.net for more information.

2

http://barrieranalysis.fhi.net/

Under the objectives, all of the materials needed for the lesson are listed. The facilitator should make sure to bring all of these materials to the lesson. In Lesson 1, we introduced the idea of an Activity Leader who will focus on the needed materials for this module. See below for more information.

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

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

Game

Following the game, all facilitators take attendance.The CHA follows up with difficulties that the Volunteers had teaching the previous lessons as well as problems they faced with their own commitments from the previous lesson.When Volunteers are meeting with women’s groups, in addition to taking attendance, review key messages from the previous lesson. Ask them about problems (and successes) they faced with their commitments from the previous lesson.

Attendance and Troubleshooting

Beginning in Lesson 2, the Activity Leader is responsible to organize materials for the Lesson Activity. The Activity Leader will be elected in Lesson 1 of this module. The Activity Leader meets with the facilitator ten minutes before each lesson to discuss the needed materials for the next lesson’s activity. The Activity Leader is responsible to talk with the others (Volunteers or mothers) during the “Attendance and Troubleshooting” to organize the materials needed for the next meeting, asking them to volunteer to bring the items. The facilitator will lead the activity, but the Activity Leader will support the facilitator by organizing the volunteers and aiding the facilitator as needed during the activity.

Next the facilitator asks about the current knowledge and practices of the CHAs (Volunteers or Mothers) in the group related to the subject of the lesson. This helps the facilitator build on what is already known and practiced by the participants.

Ask about Current Practices

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

Share the Meaning of Each Picture

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

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

Activity

The facilitator asks if there are any obstacles that prevent the caregivers from trying the new practices discussed in the lesson. The facilitator and other group members give more information or different perspectives to help CHAs (Volunteers and mothers) understand how to overcome these obstacles.

Discuss Barriers

Next is Practice and Coaching. We want to make sure that each CHA and Volunteer understands the material and can present it to others. The Health Officer (or CHA) observes and coaches CHAs (or Volunteers) as they practice teaching in pairs using the flipchart.

When Volunteers teach the mother group, they will repeat this activity asking each woman to share the key messages (and practices) that she has learned with the woman next to her. The Volunteer will go around and listen to each pair, making sure they understood the key messages correctly.

Practice and Coaching

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

Request Commitments

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

Game or SongAttendance and TroubleshootingAsk about Current PracticesShare the Meaning of Each PictureActivityDiscuss BarriersPractice and CoachingRequest Commitments

5 - 10 minutes5 - 15 minutes10 minutes10 minutes (for each picture page)15-30 minutes15 minutes5 - 20 minutes10 minutes

1 ½ - 2 hoursSuggested Citation: Hanold, Mitzi J. (2013) Orientation and Essential Nutrition Actions during Pregnancy and Breastfeeding. Washington DC. Food for the Hungry (FH), made possible through support provided by the Office of Food for Peace, Bureau of Democracy, Conflict, and Humanitarian Assistances, and the U.S. Agency for International Development under the terms AID-FFP-A-11-00012. The opinions expressed herein are those of the authors and do not necessarily reflect the view of the U.S. Agency for International Development.

Games used in the lessons are available through the HIV/AIDS Alliance. See below for full details and resources used in the development of this module.

Central Statistical Agency Addis Ababa Ethiopia and ORC Macro. Ethiopia Demographic and Health Survey (2011). Ethiopia: Calverton, Maryland, 2011.

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

USAID. Development Food Aid Program in Ethiopia Baseline Survey. (October 2011) Page 66.

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http://www.aidsalliance.org/

Lesson 1: Introduction to the Program

Caregivers2 will be able to describe the goal of the program:o We will take action to be healthy during pregnancyo We will take action to prevent malnutrition in children o We will take action to help our children grow tall, strong and healthy.

Mothers will commit to meeting with the Volunteer Community Health Worker (VCHWs) to learn new health teachings once (or twice) each month.

Volunteers (VCHWs) will commit to meet with the CHA once (or twice) each month to learn new health teachings.

Caregivers (VCHWs, CHAs and mothers) will be able to sing the Children’s Song by heart.

Materials:1. Attendance Register 2. Flipchart3. The Children’s Song (see activity)3*

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: Hello Hello Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture on flipchart pages 3-6. Activity: The Children’s Song Discuss Barriers Practice and Coaching in pairs Request Commitments

1. Game: Hello Hello– 10 minutes

2 Caregivers is the name given to all those who watch over and care for children including CHAs, Volunteers and mothers. We expect CHAs and Volunteers to commit to the same activities and practices as they are encouraging others to adopt. 3* Materials marked with an * are those which are needed for the activity at the end of the lesson.

1. Ask the participants to stand in a circle. 2. Select one participant (Person A). Ask the participant (A) to walk around the

outside of the circle and tap someone on the shoulder (Person B). Person A continues walking around the circle.

3. Person B walks the opposite way around the circle, until the two people (A and B) meet. They greet each other three times by name.

4. Persons A and B walk quickly back to the open spot in the circle (where Person B was originally standing), walking in opposite directions.

5. The person, who fills the spot first, stays in the circle. The other person becomes the leader (A).

6. He or she (A) walks around the outside of the circle and chooses someone to tap on the shoulder (Person B).

7. Continue the game as noted above. 8. Repeat the game until everyone has had a turn.

Today is our first lesson. We hope you are now energized and ready to begin!

2. Attendance and Troubleshooting – 15 minutes

When teaching Volunteers:1. CHA fills out attendance sheets for each Volunteer and mother group.2. CHA fills out vital events mentioned by each Volunteer (new births, new

pregnancies, and mother and child deaths).3. CHA asks if any of the Volunteers had problems meeting with their mother

group. 4. The CHA helps to solve the problems mentioned.5. CHA asks Volunteers to review the key practices from the last lesson. 6. The CHA asks the Volunteers about their commitments from the last meeting

and follows up with those who had difficulty trying out new practices.

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

? How? What did you do?o Did anyone (spouse, grandmother or children) interfere or tell you not

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

keep your commitments?

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o How were you able to overcome these problems?

7. CHA thanks all of the Volunteers for their hard work and encourages them to continue.

8. Ask the group to select an Activity Leader who will be responsible to coordinate the supplies and preparations for the activities in this module starting with lesson 2. The Activity Leader will make sure that each Volunteer brings one or more of the needed items for the lesson’s activities. The Activity Leader will come to each of the meetings ten minutes early so the CHA can give her or him the list of needed items and explain the activity for the next lesson. The Activity Leader will then ask for volunteers who are willing to bring the needed items during the “Attendance and Troubleshooting” section. The Activity Leader will also assist the CHA of Volunteer during the day’s activity.

9. Explain the needed items for the activity in Lesson 2. Help the Activity Leader to gather these items with the help of volunteers for the next meeting.

When Volunteers teach Mothers’ Groups:1. The Volunteer takes attendance.2. Volunteer asks about new births, pregnancies or illnesses in the families of

the mothers attending and help refer those with severe illness to the local health facility.

3. Volunteer asks the mothers to review the key practices from the last lesson. 4. Volunteer asks the mothers about their commitments from the last meeting

and follow up with those who had difficulty trying out new practices (see the questions above).

5. The Volunteer asks the group to select an Activity Leader who will be responsible to coordinate the supplies and preparations for the activities in this module starting with lesson 2. The Activity Leader will make sure that each mother brings one or more of the needed items for the lesson’s activities. (Not all lessons have materials. For example, in Lesson 2 she will help with the activity, but does not need to bring any materials). She will come to each of the meetings ten minutes early so the Volunteer can tell her the needed items and explain the activity for the next lesson. The Activity Leader asks for volunteers who are willing to bring the needed items during the “Attendance and Troubleshooting” section. The Activity Leader will also assist the Volunteer during the day’s activity.

3. Ask about Current Practices Read the questions below. Encourage discussion. Don’t correct “wrong answers.” Let everyone

give an opinion. These questions are for discussion, not for teaching.

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? What are some of the health problems children face in our community?

? Is malnutrition a problem in our community? Why or why not?

? What things can we do to prevent malnutrition?

What is malnutrition? Malnutrition is poor health caused by not eating enough foods, or eating foods that are poor in nutritional quality. Malnutrition can also be caused by disease which does not allow food (or nutrients) to be absorbed in the body.

Ask the first question to hear the participants’ (CHA, Volunteer or women’s) thoughts about health problems in the community.

Ask the second question to hear the participants’ thoughts about the prevalence of malnutrition.

Ask the last question to hear participants’ ideas about what they can do to prevent malnutrition.

o Encourage the participants to consider things they can do NOW without more money, medicine, or health clinics, etc. What simple practices can mothers and fathers do to improve their child’s health during pregnancy, at birth, and in the first few years of life?

o Encourage participants that change CAN happen in their community.o Encourage the participants that THEY can bring about change. o Encourage them that they will be trained for the next 2 years so that

they can bring change to their homes and the community. After the participants answer the last question, show the image on the

flipchart, saying “Let’s begin today’s teaching.”

Program Goals – 10 minutes

4. Share the Meaning of Each Picture

Ask the caregivers to describe what they see in the pictures on page 4. Read the captions on the flipchart out loud. Share the meaning of each picture using flipchart pages 3 and 4.

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? What do you think these pictures mean?

Together, we will prevent malnutrition in our community. We will help children grow healthy and strong. We will work to prevent child death from malnutrition. We will do this by trying new practices in our home.

Pregnant women will be healthy in pregnancy and will raise healthy children.

We will share health messages with pregnant women and women with children under age two.

These health teachings will help women to be healthy during pregnancy.

Healthy women will deliver healthy children and help them to grow well during the first two years.

? If all children are healthy (not sick all of the time), how will this affect the community?

? How will it improve the life of women and families?

Additional Information for the TrainerChildren 2 years and younger Children have the largest risk of malnutrition from 6-24 months of age. When

mothers begin adding foods to the child’s diet, the child experiences diarrhea more frequently. Frequent diarrhea often leads to malnutrition.

By focusing on children under age two, we can greatly reduce malnutrition, child illness and death.

Child Stature4

Children who are too short in height for their age are “stunted.” In Amhara over half (52%) of children younger than age five are stunted.

Stunting increases as the children age. Underweight Prevalence5

Children who are underweight are too thin for their age. In Amhara, 32% of children are too thin for their age, 11% of them are severely underweight.

4 Ethiopia Demographic and Health Survey (2011). Page 158.5 Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 49-50.

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Mother to Mother Support Groups – 10 minutes




Mothers will learn new health messages at least once each month from their community health worker.

They will learn new practices to help them raise healthy children. Together the women’s groups will try these new practices and look

for changes in the community.

The VCHW will learn a new lesson at least once each month from a Community Health Activist (CHA).

The VCHW will pass these new messages to the mothers in the community each month.

? What is the role the VCHW?? What is the role of the mother involved in the support group?? Why should mothers attend the support group?? What changes will they see in the community?

6. Activity: The Children’s Song – 15 minutes

Health Managers: Below is a sample song. Please develop a song in local languages with mothers in the community, adapting the text as necessary.

Sample song:We will take action so that our children will growTall, strong and healthy.With good food and care, and good hygiene our children will growWe can do it, we can change our community.

I can change and I can help my neighbors to changeOur children are our future, a strong and healthy future.We will take action so that our children will growTall, strong and healthy.

1. Practice the song with the CHAs, Volunteers and women in your group.2. Sing it several times so that they learn the words. 3. Challenge each participant to learn the song and share it with those who ask

about the program.

7. Discuss Barriers – 15 minutes

? Is there anything that might prevent you from participating in the group meetings each month and trying new practices (or encouraging your wife to try them)?

Ask mothers (or CHAs or Volunteers) to talk to the person sitting next to them. They will share barriers and concerns they have about the program. Together they will try to find solutions to these barriers. After five minutes, ask participants to share what they have discussed with the large group.

Help answer questions about the program. Encourage each participant to continue coming to each meeting.

Possible concerns: CHAs or Volunteers may be concerned that staff will not stay in the

community to support them forever. What will the mothers do when the program is over?

o CHAs and Volunteers will be trained so they do not need to rely on FH staff to do their work.

o After five years, CHAs and Volunteers will be fully trained to teach and train new CHAs and Volunteers.

o Mothers will have learned new skills and be able to pass their knowledge on to the next generation.

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o By working with the Ministry of Health and local government offices, we can build a strong program that will last for many generations.

CHAs and Volunteers may want to be paid for their work.o FH will train you to be strong teachers and trainers. o As a CHA or Volunteer, you will not receive money or payment.o However, your skills will make you well-known in the community.o These skills may help you to find work in the future.

The neighbor mothers are too busy to attend meetings.o Encourage CHAs or Volunteers to arrange a time that works well

with all of the neighbors.o Keep the meetings short so that women can attend the meeting and

also complete their work.

8. Practice and Coaching ─ 20 minutes

1. Ask each CHA or Volunteer to share the lesson they have learned with the person sitting next to them. (All CHAs or Volunteers will work in pairs). Each Volunteer (or CHA) teaches in the same way that they were taught.

2. In each pair, one person will teach the first half of the lesson to the other person. The other person will teach the second half of the lesson.

3. Watch, correct, and help the CHA or Volunteers who are having trouble.4. When everyone is finished, answer questions about the lesson.

When the Volunteer is teaching the mother group, she will ask each woman to discuss the things she has learned with the woman sitting next to her. They will review the new teachings verbally. The Volunteer can watch, correct and help clarify misunderstandings as she visits each pair.

9. Request Commitments ─ 10 minutes

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

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Ask each mother (or CHA or Volunteer) to say aloud a new commitment that she will make today. Each person can choose the commitment that is most important to them.

The participants do NOT need to choose a commitment from the list below. Ask first what commitments they would like to make. If they need help, read one or two of the commitments below to guide them.

For example: I commit to working with FH and the community to prevent malnutrition. I commit to working with FH and the community so that children grow healthy

and strong. I commit to sharing health messages with Volunteers and pregnant mothers

and mothers with children younger than 2 years of age every month.

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Lesson 2: CHA and VCHW Teaching Methods

Using the icons, the CHAs or Volunteers will be able to explain how to share the new teaching with others.

o Begin each lesson with game.o Then find out who is missing from your group. Call these mothers to a

second meeting or visit them in their homes sharing the health teaching that they missed.

o Ask participants about their knowledge and current practices related to the lesson you are teaching.

o Show the images and explain the key messages, adding to the information that they know already and things they are already doing.

o Lead an activity such as a demonstration, a song, or discussion around the new material.

o Ask the participants to discuss barriers or obstacles that might prevent them from trying out the new behaviors. Ask others in the group to give suggestions and advice to help them overcome these barriers.

o Ask each participant to make a commitment to try one of the new practices that she has learned.

Lesson 2 is specifically for training of the CHAs and Volunteers. You may choose not to share lesson 2 with the mother groups. However, sharing all lessons may encourage greater support from the community.

Materials:1. Attendance Register 2. Flipchart3. Role Play 2 copies*

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: Making Eyeglasses Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture on flipchart pages 7-12. Activity: Role Play Discuss Barriers Practice and Coaching in pairs Request Commitments

1. Game: Making Eyeglasses – 10 minutes

1. Say: We will begin with a game.6 You have to follow my directions. If you follow them, just as I say, you will make a pair of eye glasses with your hands. Let’s work together to see if you can make them.

Listening Only 2. Say: I will tell you what to do, but you must do it on your own. I won’t answer

questions, or tell you if you are doing it right. You must listen. 3. Read the following steps, but DO NOT DEMONSTRATE it to them. Read the

text only. a. Press and hold the tips of your thumb and first finger together on each

hand. Your fingers should form two small circles on each hand.b. Keep your fingers pressed together. Now touch the two circles

together from each hand so that they are joined in front of you. c. Next touch your remaining six fingers under your chin, so that the

palms of your hands are facing away from you.d. Keeping your fingers under your chin, move the palms of your hands

towards your eyebrows, until you can lay your thumbs across your eyebrows.

? How did you do? (With listening only, the group will have great difficulty making eyeglasses. Few will succeed)

4. Say: Let’s try it again. This time I will SHOW you and answer your questions.

Listening and Showing5. Give the same instructions as before. Answer questions. Help those who are

having trouble. 6. Show them with your hands what they should do for each step.

? What can we learn from this exercise? Encourage discussion.

People learn best when they can see and hear how to do a new thing. 6 The game is used to demonstrate the importance of using activities and demonstrations to help people

learn new practices. Talking about change is not enough. Facilitators must also teach skills and show CHAs, Volunteers and women how to do the new practices.

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People learn best when they practice the new thing with someone who has done it before.

The best way to teach others is to try the new practice yourself. Then you (the CHA or Volunteer) will know how to help others to try the new practice too.







? How? What did you do?o Did anyone (spouse, grandmother or children) interfere or tell you

not to follow your commitments? Tell the story of what happened?o What factors (people, events or chores) in your life made it

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


8. CHA asks the group’s Activity Leader to discuss the needed items for next week’s activity and solicit volunteers.



3. Volunteer asks the mothers to review the key practices from the last lesson.

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4. Volunteer asks the mothers about their commitments from the last meeting and follows up with those who had difficulty trying out new practices (see the questions above).

5. The Volunteer asks the group’s Activity Leader to discuss the needed items for next week’s activity and solicits volunteers.



? Have you ever had a good teacher? Someone who showed your something and helped you learn easily?

? What did they do that made learning easy?? What can we (as teachers of others) do to help women in

the community learn?

Ask the first question to help the participants to think of the qualities of someone who has helped them to learn.

Identify the methods and attitudes that helped the person to be an effective teacher.

Ask the last question to help the participants reflect on how they can take their experiences and use it to teach others effectively.

After the participants answer the last question, show the image on the flipchart, saying “Let compare your ideas with today’s lesson.”

Games and Attendance – 10 minutes



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When you meet with mothers’ support groups, always begin the meeting with a game or song.

Games help people to relax and have fun. Repeat the game that you learned from your trainer.

Take attendance so you know which mothers are missing. Visit the women who have missed the group lessons. Repeat the lesson to them in their home. Report the attendance to your supervisor each time you meet him.

Additional Information for the TrainerFeeling Safe Games help men and women to feel “safe” or at ease in the company of their

peers. When CHAs, Volunteers or mothers feel safe they are more likely to share their experiences, talk openly about their struggles and more likely to try the new practices at home.

Attendance If CHAs, Volunteers or women are not coming each month (or every two

weeks) to meetings, then we know something is wrong. Only when we make a record of those missing, can we discover the problems and find solutions.

Always take attendance. Follow up with those who are missing.

Introducing the Health Teaching – 10 minutes



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Introduce the topic by asking what the women already know about it. Ask them about what they are currently doing related to the new

topic. If you are sharing a story about hand washing ask, “What have you

learned about hand washing? How often do you wash your hands?” If you are sharing a story about covering pots, ask, “How can we

protect our foods from germs? What do you do to protect your food from germs? Why?”

Listen to their responses. Do not correct them. Let everyone share their thoughts.

Share the meaning of each picture on the flipchart. Ask the women, “What do you think these images mean?” Affirm those who answer. Explain the key message or meaning of each image.

Do an activity with the women to help them understand the lesson. In this picture, the women are making porridge. Activities may be a cooking lesson, a song, a demonstration or a

discussion.

Additional Information for the TrainerAsk about Current Practices If the facilitator discovers that all of the CHAs, Volunteers or mothers are

already practicing the new behavior, the facilitator does not need to spend the entire lesson explaining the behavior and giving reasons for change.

Based on their responses, the facilitator will adapt the messages so they are relevant to the group.

Adult Learning and Discovery Adults need to look, analyze and respond to what they are seeing. Adults

learn best when they “discover” the answers (or teachings) on their own instead of having the facilitator tell them “the answers.”

Encourage group discovery and learning through discussion of the images. Seeing and Doing No matter what you are teaching, if you only talk about the new practice but

never demonstrate it; don’t expect the learners to try the new practice at home.

Demonstrate it for them. Then ask each and every one in the group to try the new practice with you.

If the CHA or Volunteer is male and can’t demonstrate the behavior (such as breastfeeding positions), ask a woman in the group to demonstrate for everyone.

Each lesson has an activity listed in the lesson plan to help you.

Discuss Barriers and Request Commitments – 10 minutes

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Discuss barriers, problems and concerns the women have about the new practices.

Ask, “Is there anything that might prevent you from trying these new practices?”

Find ways to help the women overcome these barriers. For example, “You said that you don’t have lids for your pots, can you

make them out of reeds?” You said you don’t know how to make lids, “Can I show you how?”

Ask each woman to make a commitment to try one of the new practices. For example, one mother might commit to buy pots with lids. Another mother might commit to save money to purchase lids. Another mother might commit to making her own lids to keep our flies. Each mother can choose her own commitment.

Additional Information for the Trainer Even though the flipchart says, “ask each woman,” these practices are for

each CHA and Volunteer as well. Make sure all participants in group meetings discuss barriers, make commitments, and participate in all of the activities in the lesson plan.

Overcoming Barriers We are teaching CHAs, Volunteers and mothers to help them move towards

change. We have to help them remove barriers and obstacles that prevent them from trying the new practice. It is not the facilitator’s responsibility to come up with all the answers.

Encourage others in the group to offer suggestions and solutions to help their peers. Encourage discussion. Encourage hope that all obstacles can be overcome if the group works together to overcome them.

If it is in your power to remove the barrier (by advocating for the CHAs, Volunteers or women’s concerns with others) do everything you can to make it happen.

Commitments

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Many studies have shown that if learners make a verbal commitment in front of others, they are more likely to remember the commitment and actually follow-through on the commitment.

By allowing the learners to make their own commitments, they take responsibility and set goals that are relevant to their family.

7. Activity: Role Play – 15 minutes

Note that the Module 1 Flipchart does not contain the small icons shown here in the lesson plan. Beginning with Module 2, the small icons are seen on the back of the flipchart. Review the icons again when teaching Module 2.

1. Ask each CHA and Volunteer:

? What is the first thing that you should do when teaching others?(Game)

? What should you do next? (Take Attendance)Add: This is also a good time to ask them about the commitments they made at the last meeting. What did you commit to do? How did it go?When CHAs are training Volunteers they will also ask the Volunteer about the last training - finding out if there were any problems with training or lesson. Health Officers will help CHAs with questions they may have about last week’s lesson.

? What happens after attendance? Continue reviewing each step of teaching a lesson with CHAs and Volunteers ending with requesting a commitment.

2. Say: Now let’s watch a role play to see what happens when a CHAs or Volunteer visits a mother in her home. This role play takes place after several lessons have been taught. (See the printed role play on pages 27-28).

3. Ask for two volunteers to act out the role play with you. 4. Give one copy of the role play to each CHA or Volunteer. For a low-literate

audience, ask one literate volunteer to read the role play. Each volunteer should listen and then act out each sentence after it is read. Adapt as needed.

5. After the role play, read the discussion questions below.

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? What did you learn from this role play?

6. Encourage discussion. Add any of the following points that are not mentioned.

a. If someone misses a meeting, the CHAs or Volunteer should go to the home and reteach the lesson, (or reschedule a meeting if more than one person missed the meeting).7

b. The CHAs or Volunteer repeats what the mother said in a different way (paraphrasing). This helps to clarify and confirm what the mother has said.

c. The CHAs or Volunteer did not force the mother to make a commitment. She mentioned the benefits of trying the new practice.

d. The CHAs or Volunteer helped the women overcome their doubts or barriers. o She asked: “What do you think about this lesson? Is there anything

that might make it difficult for you to only give breast milk for the first six months?”

o She suggested: “The nurse at the health post can read the growth chart and show you that the child is growing well.”

o She asked the mother to make a commitment and asked her about commitments she made at the last meeting.

She said: “Would you be willing to commit to exclusively breastfeed your infant until six months, and then begin slowing adding foods?”

She said: “You said that you would commit to putting the newborn child to the breast immediately after she was born. Did you do that?”


? What do you think about these ideas? Is there anything that might prevent you from using this format to teach others?

Ask mothers (or CHAs or Volunteers) to talk to the person sitting next to them. They will share barriers and concerns they have about the new teaching. Together they will try to find solutions to these barriers. After five minutes, ask participants to share what they have discussed with the large group.

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

7 When the health officer is recording the attendance of the Volunteer and Mother Groups, he will only mark absent for those who 1) missed the group meeting and 2) did not receive a follow up visit or meeting to hear the teaching that they missed.

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Possible concerns: Some Volunteers may be illiterate and unable to read the text on the

flipcharts.o We know many Volunteers are not able to read. This is not a problem.o They need to listen carefully to the things that the CHA shares about

each image, and remember them.o Repeat the lesson as closely as you can, using your memory and the

images on the flipchart to guide you. Some may worry that they will forget some of the steps in the lesson.

o Encourage them to practice using the steps.o Remind them that with practice, they will be able to succeed.








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For example: I will begin each lesson with a game. I commit to looking for those who are absent at each meeting and trying to

meet them later in the week. I commit to asking about the participants’ knowledge and practices before

sharing the key messages. I will always ask for a commitment from the participants in the group.

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Role Play: Barriers and Commitments

This role play will only be used with CHAs or Volunteers and does not need to be shared with mother groups.

Setup: This woman was sick and could not attend the group meeting. The CHA or Volunteer goes to her home to shares the messages from the flipchart. The CHA or Volunteer sits with the Mother and Mother-in-Law during the role play.

Explain: The CHAs or Volunteer is sitting with a mother in her home. She has just shared messages about breastfeeding with the mother and her mother-in-law. (She has already taken attendance, asked about current practices and shown all of the flipchart pages.) Listen to how the CHAs or Volunteer discusses barriers and requests a commitment.

CHAs or Volunteer: What do you think about this lesson? Is there anything that might make it difficult for you to exclusively breastfeed for the first six months of your infant’s life?

Mother-in-Law: I have heard that it is best to give only breast milk to an infant until he is six months old. Then at six months add foods, but continue breastfeeding. I have never heard such teaching before.

Mother to Mother-in-Law: You are right; we have never heard such teaching. It’s true that infants don’t need other foods or drink before they are six months old. Even some women in our villages wait to give food until the infant is six months old.

Mother-in-Law: Yes. Some women say that giving food earlier gives the infant diarrhea.

CHAs or Volunteer: So it sounds like although many mothers give foods early, some wait to give foods to prevent the infant from getting illnesses.

Mother-in-Law and Mother: Yes.

CHAs or Volunteer: What do you think? Do you think it is possible that waiting to give foods or drink might prevent illness?

Mother: It may be true. I have heard your teaching and the experiences of others in the community. But how can we be sure that our children are growing well with just breast milk?

CHAs or Volunteer: The nurse at the health post can read the growth chart and show you that the infant is growing well. Would you be willing to commit to trying to exclusively breastfeed your infant until six months, and then begin adding foods?

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Mother: Yes, it is possible. We will talk to our family and make a decision with them before the next group meeting.

CHAs or Volunteer: Okay. I will ask you at our next meeting. Now let’s examine what you have done since my last visit. You said that you would commit to putting the newborn to the breast immediately after she was born. Did you do that?

Mother: Yes, I made the commitment and I followed through. Look. She is very strong and healthy now.

CHAs or Volunteer: That is wonderful. You are trying new things. I can even see that you child is happy and healthy too.

Mother-in-Law and Mother: Thank the CHAs or Volunteer for coming.

CHAs or Volunteer: Remind her of the next group meeting. Encourage her to come. Depart.

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Lesson 3: Nutrition and Care during Pregnancy and Breastfeeding

Caregivers will be able to list the things that pregnant mothers need to do to stay healthy.

o Eat one additional meal (or two small snacks) each day. o Add a sprinkle of iodized salt to foods. o Sleep under a mosquito net each night.

Caregivers will be able to list the things that breastfeeding mothers need to do to stay healthy (and keep the infant healthy):

o Eat one additional meal (or two small snacks) each day. o Sleep with your child under a mosquito net each night. o Eat nutrient rich foods. o Visit the health center at least four times during pregnancy.o Visit the health center within two days 8after giving birth.

Materials:1. Attendance Register 2. Flipchart3. (optional) Samples of snacks mothers can eat between meals*

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: Stew Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture on flipchart pages 13-18 Activity: Healthy Snacks Discuss Barriers Practice and Coaching in pairs Request Commitments

8 In the flipchart, it says three days. However, two days is essential to protect women and newborns from danger. Module 3 was updated so that is says two days.

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1. Game: Stew – 10 minutes

1. Divide the participants into three or four groups. Give each group a name of a vegetable used in a stew such as tomatoes, greens, okra, fish or lentils.

2. The participants should sit in chairs (or on mats) in a circle, mixing with other groups so they are not sitting next to someone from their food group. The facilitator stands in the center of the circle and shouts out the name of one of the foods.

3. All of the participants in this food group must change places with one another. The facilitator tries to take one of their places as they move, leaving one participant without a seat. She becomes the new facilitator.

4. The new facilitator stands in the middles and shouts another food group and the participants in this group change places with each other while she tries to steal one of their seats.

5. If someone says, ‘stew’ all participants have to change seats.6. Continue until everyone is laughing.

Now that we are energized and ready for our lesson, let’s begin!








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8. CHA asks the group’s Activity Leader to discuss the needed items for next week’s activity and solicit volunteers.



3. Volunteer asks the mothers to review the key practices from the last lesson. 4. Volunteer asks the mothers about their commitments from the last meeting

and follows up with those who had difficulty trying out new practices (see the questions above).



give an opinion. These questions are for discussion, not for teaching.? What practices help a mother to be healthy during

pregnancy?? What practices help a mother and her infant stay healthy

while breastfeeding?? Which of these do you (or your wife) practice regularly?

Ask the first two questions to hear what the participants already know about healthy pregnancy and breastfeeding practices.

Ask the last question to hear how often they (or their wives) have done these practices. Knowing about healthy behaviors is not enough. Find out how many participants practice the things that they have mentioned.


Feeding and Care during Pregnancy – 10 minutes

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Eat one additional meal (or two small snacks) every day during pregnancy.9

If you can’t eat one additional meal, eat two small snacks between meals.

Extra food helps you and the baby to grow well during pregnancy. Eat liver and meat like chicken and fish. Eat beans, peas, lentils, potatoes, pumpkins, red sweet potatoes,

carrots, collard greens, cabbage and kale and Swiss chard. Eat fruits like mangos, papayas and bananas.

Do not fast during pregnancy to protect your child from harm.

Eat foods with a sprinkle of iodized salt. Iodized salt helps the infant’s brain to grow well during pregnancy. Add iodized salt to foods each day for the entire family.

Sleep under a mosquito net each night. Malaria is very dangerous during pregnancy. Sleep under a treated net to prevent malaria.

? Do you normally fast during pregnancy? How do you think this impacts the growth of the child?

? What taboos or customs make it difficult for you to follow these practices? How can we overcome these obstacles?

Additional Information for the TrainerSnacks Snacks are small foods eaten between meals. Uncooked snacks are easiest

for women to prepare. Snacks might include kola nuts, fruit and raw vegetables like carrots. Coffee is not a snack.

Possible cooked snacks include porridge and gomen (collard greens). Gomen is especially helpful for mothers after delivery when constipation is common. Gomen helps to soften feces making it easier to defecate.

Fasting

9 The flipchart says only, “Eat one additional meal” we have added “or two small snacks” as it is more feasible for women in this region. The following foods have been added to the list of foods to promote during pregnancy: lentils, pumpkins, red sweet potatoes, collard greens, and papayas. A note about fasting was also added and the two questions have been changed.

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Fasting during pregnancy is dangerous to the growth of the infant and pregnant mother. Studies in have shown that the 7 year old children of mothers who fasted for a month were worse at math, reading and writing compared to children whose mothers did not fast. The children had lower birth weights, and reported more health problems later in life.10

Encourage pregnant and exclusively breastfeeding mothers not to participate in fasting days to protect their own health and that of their child.

For mothers who feel they must participate, encourage them to prepare family foods which include meat, fish and eggs on non-fasting days.

Negative Cultural Practices and Taboos Cultural practices such as “eating down,” fasting, and the many food taboos

during pregnancy put mothers and their growing infants at great risk of malnutrition and death.

Eating snacks may also be considered taboo when all foods are commonly shared in the family.

Encourage discussion of these practices with the women in small groups (and as needed, elders in the community). Are these practices helping or hindering the growth of children? Are these practices helping or hindering our nation? Our people?

Encourage culturally appropriate ways to honor tradition, but also ensure that the lives of pregnant mothers, breastfeeding mothers, and their infants and newborns are protected from harm.

Iodized salt11

According to the World Health Organization, a country’s salt iodization program is considered to be good if 90% of the households are using iodized salt.

In the baseline survey in Ethiopia, 94% of households had salt. However only 19% of these households had salt with iodine (or iodized salt).

Only 1 in 10 women with a child born in the last five years lived in a house with iodized salt.

Iodine and Deficiency Iodine is a mineral which is needed for the development and growth of the

body. Too little iodine can cause miscarriages, stillbirths (infants born dead) and low

birth-weight infants (infants born too small) who have lower rates of survival. Iodine helps the growing infant’s brain to develop. Too little iodine during

pregnancy and early infancy slows the brain’s growth making it difficult for the child to learn and work well in school.

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.

Mental deficiencies have a negative impact on nation’s productivity. Studies have shown that the mental losses caused by iodine deficiencies cost the Ethiopian economy 1.35 billion ETB per year.12

Symptoms of Iodine Deficiency

10 Almond D, Mazumder B, Van Ewijk R. Fasting During Pregnancy and Children’s Academic Performance. NBER Working Paper No. 17713. Cambridge, MA: National Bureau of Economic Research; 201111 Ethiopia Demographic and Health Survey (2011). Pages 178-179,188.12 Lab Space. Childhood and maternal malnutrition in Ethiopia. Available: http://labspace.open.ac.uk/mod/oucontent/view.php?id=452005&section=8.3.2

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Goiter (a bulge on the front of the throat) and hypothyroidism (too little iodine) are the signs of iodine deficiency.

Hypothyroidism is difficult to diagnosis without blood tests. Signs of hypothyroidism include feeling tired, depressed, dry skin, feeling colder than usual, and constipation.

Feeding and Care while Breastfeeding – 10 minutes




Eat one additional meal (or two small snacks) every day during breastfeeding.13

Eat shiro, potatoes, beans, meat, chicken papaya, mango, carrot, collard greens and kale to help you regain strength after delivery.

If you can’t eat one additional meal eat two small snacks between the family meals.

Extra food helps you to remain healthy during breastfeeding. Drink more fluids than normal to increase breast milk.

Sleep with your child under a mosquito net each night. Malaria is very dangerous for young children. Sleep under a net to protect yourself and your child.

? How do ITNs prevent malaria?

Additional Information for the TrainerITN ITN stands for insecticide treated net. The net has a chemical on it that kills

mosquitoes that land on the net. It is extremely effective at protecting families from bites and killing mosquitoes in the home.

13 This text has been changed. It is incorrectly written as “eat two additional meals every day during breastfeeding” on the flipchart. IT should say, “Eat one additional meal (or two small snacks) every day during breastfeeding. Collard greens were also added to the list of foods.

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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.

Malaria in Pregnancy According to the World Health Organization (WHO), malaria accounts for over

10,000 maternal and 200,000 newborn deaths each year.14

A recent study from Mozambique found that 10% of maternal deaths were directly attributed to malarial infection.15

For those who survive, malaria is known to cause increased risk of miscarriage, premature delivery, low-birth-weight babies, and infant death.

Dietary Intake16 The women’s dietary diversity score is used to measure the number of food

groups eaten by women (ages 15-49). Women need to consume at least 4 of the 9 food groups to have adequate dietary diversity.

In the baseline survey, the average number of food groups eaten was 2.5 in CRS areas and 3.6 in FH’s areas.

Fewer than 20% of women were eating from the following food groups: organ meats, meats, eggs, dark green leafy vegetables, and other fruits or vegetables.

Coffee Pregnant and breastfeeding women should avoid coffee and tea taken

directly after meals. They both contain tannins which reduces the body’s ability to absorb iron (increasing the risk of anemia). Wait at least one hour after eating to drink coffee or tea.

Coffee is not considered a snack.

Health Center Visits – 10 minutes



? What do you think these pictures mean?14 World Health Organization Web site, authors. Global Malaria Programme: pregnant women and infants. [Accessed July 30, 2009]. http://apps.who.int/malaria/pregnantwomenandinfants.html.15 Menéndez C, Romagosa C, Ismail MR, et al. An autopsy study of maternal mortality in Mozambique: the contribution of infectious diseases. PLoS Med. 2008;5:e44.16Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 56.

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http://apps.who.int/malaria/pregnantwomenandinfants.html

Visit the health center at least four times during pregnancy. Go as soon as you know you are pregnant. The health worker will monitor the growth of the mother and child. The health worker gives iron supplements to prevent anemia (weak

blood) and vaccinations to prevent tetanus. The health worker looks for problems that might cause a difficult birth.

Visit the health center within two days17 of giving birth. Return after one month (45th day) for another checkup. The health worker gives vitamin A to protect the mother and child

(through breast milk) from illness.

Additional Information for the TrainerPurpose of Antenatal Care Antenatal care helps to prevent poor pregnancy outcomes when it is started

early in the pregnancy (at first signs of pregnancy) and continued through delivery.

You will learn more about pre- and postnatal care in Module 3. Antenatal Care in Ethiopia (2011) 18

Four out of every ten women (44%) had at least one antenatal care visit during their last pregnancy. However, only 17% of mothers made four visits during pregnancy.

The average gestational age of the first ANC visit was 4.5 months! The first visit should fall within the first three months of pregnancy.

Maternal Mortality Rate In countries where the national income is low (like Ethiopia), over half (60%)

of maternal deaths occur in the week after delivery. Of those who die after birth, most (45%) of them die within 24 hours after

delivery, 23% of the deaths occur in the next five days (days 2-7).19

The most common causes of maternal death after delivery are bleeding and infection. Delivery at a health facility and appropriate care in the first hours and days after delivery can prevent the majority of these deaths.

Postnatal Care in Amhara Only 5% or five women out of 100 returned to the clinic (or received a visit by

community health worker) within two days after delivery for a postnatal visit.20

17 The flipchart incorrectly says three days. It should be two days.18 Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 56. 19 Li, XF, Fortney, JA, Kotelchuck, M, and Glover, LH. 1996. The postpartum period: The key to maternal mortality. International Journal of Gynecology and Obstetrics 54(1): 1-10.20 Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 130

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7. Activity: Healthy Snacks – 15 minutes

1. Lead a discussion regarding snacks that are healthy for pregnant and lactating mothers to eat in between meals.

2. Show snacks that you have brought. 3. Encourage CHAs, Volunteers and mothers to offer up other ideas of snacks

that can be easily prepared (small foods that do not require cooking are best).

4. Possible snacks might include: Kola nuts or other nuts Popped corn Fruits like avocado, watermelon or tomato Vegetables which can be eaten raw like carrots Groundnut paste eaten with injera or bread Porridge Fried or boiled snacks like boiled potato or boiled egg

5. Discuss any taboos which might prevent them from following the guidance. Work together to find ways to help Volunteers and mothers overcome these cultural barriers.

6. Ask each mother which of these snacks would be easiest for her to prepare for herself during pregnancy.

7. Encourage each CHA, Volunteer or mother to decide upon 1-2 snacks that they can commit to trying (or encouraging their wife to try).


? What do you think about these ideas? Is there anything that might prevent you from trying these new health practices (or encouraging your wife to adopt these practices)?

36











For example:

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I will go to the health facility (or encourage my wife to go) at least four times during pregnancy.

I will eat (or encourage my wife to eat) two small snacks between meals during pregnancy and lactation.

I will sleep (or ensure that my wife sleeps) under a mosquito net during pregnancy.

I will add (or ensure that my wife adds) a sprinkle of iodized salt to family foods during and after pregnancy.

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Lesson 4: Anemia Prevention

Eat organ meat and animal flesh at least once each week for strong blood. Pregnant women will take iron pills each day during and after pregnancy for

strong blood. Pregnant women will sleep under a mosquito net each night to prevent

anemia from malaria. Caregivers will believe that they are able with their current time and skills to

prevent anemia (increased self efficacy).21

Materials:1. Attendance Register 2. Flipchart3. A bottle of iron pills*4. A container of manufactured iodized salt*22

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: Etsegenet Says Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture on flipchart pages 19-22 Activity: Checking Symptoms Discuss barriers Practice and Coaching in pairs Request Commitments

1. Game: Etsegenet Says – 10 minutes

1. Ask the participants to stand in a circle. 21 Self Efficacy is a behavioral determinant in barrier analysis: if caregivers believe that they have the skills, time and confidence (it’s not too hard) to prevent anemia, they are more likely to try the new practices. 22 Make sure the salt you are showing contains iodine. Rock salt sold in the markets does not contain iodine. Look for sealed containers prepared in a factory that have the word “iodine” on the package.

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2. The object of this game is to do what “Etsegenet says.” 3. The participants should only do the activity if the facilitator begins the

sentence with “Etsegenet Says…” For example, “Etsegenet says, jump up and down.” “Etsegenet says, touch your toes.” “Etsegenet says, kneel down.”

4. Do several “Etsegenet says…” then give an instruction without mentioning Etsegenet. “Etsegenet says jump up and down. Sit down.” Those who sit down must leave the circle.

5. Continue giving new commands until only one person remains.

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


When teaching Volunteers:1. CHA fills out attendance sheets for each Volunteer and mother group

(beneficiary group).2. CHA fills out vital events mentioned by each Volunteer (new births, new


groups. 4. The CHA helps to solve the problems mentioned. 5. CHA asks Volunteers to review the key practices from the last lesson. 6. The CHA asks the Volunteers about their commitments from the last meeting







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7. CHA asks the group’s Activity Leader23 to discuss the needed items for next week’s activity and solicit volunteers.



3. Volunteer asks the mothers to review the key practices from the last lesson. 4. Volunteers asks the neighbor mothers about their commitments from the last

meeting and follows up with those who had difficulty trying out new practices (see the questions above).


3. Ask about Current Practices Read the questions below. Encourage discussion. Don’t correct “wrong answers.” Let

everyone give an opinion. These questions are for discussion, not for teaching.

? What is anemia? What causes it?? How do you prevent anemia (or weak blood)?? Which of these practices are you doing currently? Why or

why not?

Anemia is when your red blood cell levels become low. Your red blood cells deliver oxygen to your organs and other body parts. Anemia can be very serious if left untreated. Low oxygen in your blood can lead to paleness, weakness, and breathlessness.

Ask the first question to hear the participants’ current knowledge of anemia and its causes.

Ask the second question to hear the participants’ current knowledge of practices that prevent anemia.

Ask the last question to hear the current practices of the participants in your group.

o Try to address barriers they mention at the end of the lesson during the “Discuss Barrier” section.


Signs of Weak Blood (Anemia) – 10 minutes

23 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 health officer, CHA or Volunteer.

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Weak blood (anemia) causes physical weakness. Weak blood is called anemia. Weak blood is common in pregnancy. Anemia makes the body weak. It causes shortness of breath and dizziness. It can lead to depression.24

If the blood is weak, the tongue and inside of the lips and eyelids are pale.

These are signs that the woman has anemia. If the blood is healthy, the inside of the lips and eyelids are red in

color.

? Do you have signs of weak blood?

Look for women in the group who are showing signs of weak blood.

? How can pregnant women prevent weak blood?

Additional Information for the TrainerIron 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. 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.Anemia in Ethiopia Forty-four percent of children ages 6-59 months are anemic.

24 The last bullet is section one was added to the lesson plan (it is not listed on the flipchart).

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Seventeen percent of women ages 15-49 are anemic.25

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

and childbirth than women without anemia. 26

Women with moderate to severe anemia are also more likely to lose a greater amount of blood during childbirth. If there is severe blood loss that cannot be stopped, this is called post-partum hemorrhaging. Post- partum hemorrhaging is the leading cause of death in Africa.

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.

Women with anemia are more likely to have post-partum depression (extreme sadness) after delivery that can last for weeks, even months.

Prevention of Weak Blood (Anemia) – 10 minutes


Ask the caregivers to describe what they see in the pictures on page 22. Read the captions on the flipchart out loud. Share the meaning of each picture using flipchart pages 21 and 22. Show the CHAs, Volunteers and mothers an iron pill bottle. Discuss the closest health center or facility where iron pills can be accessed.


Eat organ meats and animal flesh at least once a weak for strong blood.

Organ meat is the best food to build strong blood. Fish and meat build strong blood. Peas, kale and beans also help to build strong blood. However they are not as good as organ meats.

Prevent anemia during pregnancy by sleeping under a mosquito net and taking iron pills each day.

Many women have anemia during pregnancy. Taking iron tablets for the last six months of pregnancy is the easiest

way to build strong blood. Complete the course of iron tablets after giving birth if not finished

25 Ethiopia Demographic and Health Survey (2011). Page 155. 26 Brabin, B. J., Hakimi, M., and Pelletier, D. (2001). An analysis of anemia and pregnancy related maternal mortality. Journal of Nutrition, 131(2S-2), 604S–614S

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with the tablets. Malaria also causes weak blood. Sleeping under a net prevents malaria.

? Did you sleep under a bed net last night? Why or why not?? Which one of these things can you do to help your blood grow stronger?

Additional Information for the TrainerIron Pills Iron pills (also referred to as ferrous sulfate) and prenatal vitamins should be

available to pregnant and lactating women at health centers. Women should take iron pills daily, after their first prenatal visit for at least

six months. Six months of pills is called a “course” or the complete dosage needed during

pregnancy. Do not take iron pills with meals. It reduces the effectiveness. The best time

to take iron is right before bed. In Ethiopia, the proportion of women who received iron tablets for 6 months

during their last pregnancy was only 2%. That means 98 out of 100 women did not have enough iron in their diet during pregnancy.27

Side Effects Many women experience side effects when taking iron pills. Side effects

include stomach upset, heartburn, and constipation. Taking the pills before going to bed helps to reduce discomfort. 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 full dose.

6. Activity: Checking Symptoms – 15 minutes

1. Show the participants the package of iodized salt. Explain what they should look for on the package (the name “iodine” or “iodized”). Iodine is added to salt. Not all salt contains iodine!

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

3. Ask the group,

? How many of you add iodized salt to your foods each day? 27 Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 57.

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4. Ask these participants to share with the group how they use iodized salt. 5. Ask the participants in the group to look at each other’s tongues, and the

insides of the lips and eyelids. Examine the nails. 6. Find the participants with the reddest tongues, and insides of the lips and

eyelids. Find the participants 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 participants 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.


? What do you think about these ideas? Is there anything that might prevent you from trying these new health practices (or helping your wife adopt these practices)?




45








For example: I will sleep (or encourage my wife to sleep) under a mosquito net each

night during pregnancy. When pregnant, I will ask (or encourage my wife to ask) for iron pills at

the health facility. I will eat (or ensure that my wife eats) small amounts of fish, organ meat

or red meat each week during pregnancy to prevent anemia.

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Lesson 5: Immediate Breastfeeding

Mothers will begin breastfeeding within one hour after birth to help the placenta exit the body.

Mothers and caregivers will give only breast milk to infants at birth until six months of age, never giving butter, water, animal milk, porridge or other food or liquids.

Mothers and caregivers will believe that the first yellow milk and colostrum will perfectly satisfy the thirst and hunger of the infant for the first six months of life (increased action efficacy).28

Materials: 1. Attendance Register 2. Flipchart3. Small rocks, eggs or other objects that are the same size as the balls

shown in the picture on page 52.*

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: The Whisper Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture using flipchart pages 23-26 Activity: Belly Balls Discuss Barriers Practice and Coaching in pairs Request Commitments

1. Game: The Whisper ─ 10 minutes

1. Participants sit in a circle.

28 Perceived action efficacy is a behavioral determinant in barrier analysis: if caregivers really believe that breastmilk and colostrum will satisfy the infant’s thirst and hunger for the first six months (it really works), they will be more likely to practice it.

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2. The facilitator thinks of a very long message such as, “I’m going to the market to buy some bananas and teff and then I am going to walk to the well to fetch water.”

3. The facilitator whispers this message into the ear of the person on the right. The person receiving the message repeats the message to the next person in the circle.

4. Continue passing the message from one person to another until it reaches the last person in the circle.

5. Ask the last person to say the message aloud.6. Compare the final message to the original message. (Usually the message

changes as it is passed around the circle.)7. Repeat the game with a new message.

? What can we learn from this game?o Sometimes messages change as it is passed from one person to

another!o When we do not hear or do not understand, we must ask questions and

ask for clarification.o Because the flipchart teaching is passed from one person to many

others, we must be careful to hear the message clearly and repeat it just as we have heard it.

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

2. Attendance and Troubleshooting ─ 15 minutes


pregnancies, and mother and child deaths).3. CHA asks if any of the Volunteers had problems meeting with the Mothers’

Groups. 4. The CHA helps to solve the problems mentioned. 5. CHA asks Volunteers to review the key practices from the last lesson. 6. The CHA asks the Volunteers about their commitments from the last meeting



? How? What did you do?

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o Did anyone (spouse, grandmother or children) interfere or tell you not to follow your commitments? Tell the story of what happened?

o What factors (people, events or chores) in your life made it difficult to keep your commitments?






3. Volunteer asks the mothers to review the key practices from the last lesson. 4. Volunteer asks the neighbor mothers about their commitments from the last





? What is the first drink most mothers give to their infants? Why?

? What did you give to your last child to eat or drink at birth?? When is the best time to begin giving children water,

butter, porridge or other foods and liquids (excluding breast milk)?

Ask the first question to hear the opinions of those in your group. Ask the second question to hear about the practices of the participants.

Listen to the foods and liquids that they gave to the newborn. Ask the last question to hear the participants’ opinion about giving other

foods and liquids (excluding breast milk). After the participants answer the last question, show the image on the

flipchart, saying “Let compare your ideas with today’s lesson.”

29 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 Health Officer, CHA or Volunteer.

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Breastfeed Immediately after Delivery - 10 minutes




Begin breastfeeding within one hour after birth. Hold the newborn close (skin to skin) against your body to keep the

newborn warm. Wrap a blanket around the two of you. The mother’s thick milk (inger) gives the newborn protection from

illness like diarrhea and respiratory infection.

Immediate breastfeeding helps the placenta exit the body. Offering the infant inger satisfies the infant and helps the mother’s

body to let go of the placenta. Offer the infant inger helps slow the mother’s bleeding. Offering the infant inger encourages the mother’s thin milk to come.

Additional Information for the TrainerBreast is Best Breast milk contains all the nutrients necessary in the first few months of life. The mother’s antibodies (disease fighting cells) in breast milk help fight

illness and prevent sickness in the infant. Offering other foods and liquids besides breast milk exposes infants to germs

that cause infection and diarrhea. The best liquid for the infant is breast milk. Other liquids, like tea, coffee or

hot water mixed with herbs, can cause more harm. Offering other foods and liquids besides breast milk decreases infants’

sucking at the breast and in turn reduces the mother’s milk production. Other foods and liquids do not contain all of the nutrients needed to satisfy

the infant’s needs.

Breast Milk Alone Is Best - 10 minutes

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Give only breast milk to infants from birth to six months. A mother’s breast milk contains all of the elements necessary for the

growth of the newborn until six months A mother’s breast milk satisfies the infant’s need of fluid even in hot

climates.

Never give butter, water, animal milk, porridge or others foods and liquids to infants.

Porridge, butter, animal milk, water, coffee, tea30, and other foods will cause diarrhea and sickness.

? What do people feed newborns at birth?? What do they do with the yellow breast milk (“inger”)?? How could we teach the local community about the harmful effects of

giving butter to newborn infants at birth?

Additional Information for the Trainer Breastfeeding in Ethiopia The exclusive breast-feeding rate in DFAP implementation area is 66%. This

figure is higher than the national figure which, according to Ethiopia Demographic and Health Survey 2011, was 52%.31

The percentage of young children who are exclusively breastfed decreases sharply from 70 percent of infants age 0-1 month to 55 percent of those age 2-3 months and, further, to 32 percent among infants 4-5 months.32

Additional Foods and Liquids In addition to breast milk, 19% of infants younger than six months are given

water, while 14% receive animal milk in addition to breast milk, and 4% are given other liquids and juice.33

30 In the lesson plan I have added “coffee and tea.” This was not part of the printed flipchart. 31 Development Food Aid Program in Ethiopia Baseline Survey (October 2011) Page 66.32 Ethiopia Demographic and Health Survey (2011). Page 155, 164. 33 Ethiopia Demographic and Health Survey (2011). Page 166.

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All of these infants are at great risk of diarrhea, infection and in turn, malnutrition.

6. Activity: Belly Balls - 20 minutes

Materials Needed: Find small rocks, eggs or other objects that

are the same size as the balls shown in the picture.

1. Ask the participants in the group.

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

2. 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 Day 1).

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

3. 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 and night.

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

4. Explain: At three days old, the infant’s stomach is the size of this small rock (use the rock which represents Day 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.)

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5. Explain: A mother needs to feed an infant often. This is because the stomach is very small. An infant needs frequent feedings throughout the day and night 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 ?

6. On the 10th day of life, the infant’s stomach is the size of this rock (show the rock which represents Day 10). By the 10th day the mother has a lot more milk. However she still needs to feed the infant often night and day to fill the infant’s stomach and let them rest to digest.

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

7. Discuss Barriers ─ 15 minutes


Ask mothers (or CHAs or Volunteers) to talk to the person sitting next to them. They will share barriers and concerns they have about the new teaching. Together they will try to find solutions to these barriers. After five minutes, ask participants to share what they have discussed with the large group. Help find solutions to their concerns. If someone offers a good solution to another person’s concern, praise them and encourage others to consider this solution.



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For example: I will give my child (or encourage my wife to give) the yellow milk (inger)

in the first hour after birth. I will never give (or ensure that my wife does not give) butter, water,

porridge or any offer foods and liquids to my infant until he/she is six months of age.

I will offer (or ensure that my wife offers) only breastmilk to the infant for the first six months of life.

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Lesson 6: Exclusive Breastfeeding from Birth to Six Months

Mothers will breastfeed day and night whenever the infant shows signs of hunger.

Mothers and caregivers will hold their infant close, supporting his head and body when breastfeeding.

Mothers will wait until the infant’s mouth is wide open, before bringing the infant to the breast.

Materials: 1. Attendance Register 2. Flipchart

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: Mirrors Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture using flipchart pages 27-32 Activity: Good Attachment Discuss Barriers Practice and Coaching in pairs Request Commitments

1. Game: Mirrors ─ 10 minutes

1. Everyone will work with a partner for this game (including the facilitator). 2. One person in each pair is a "mirror." The other person is the "actor." The

"actor" will move their body in different ways. The mirror must copy everything that the actor does.

3. The facilitator demonstrates with his partner until everyone understands. 34

4. Then the others pair up and try it.

34 Image from International HIV/AIDS Alliance (2002).

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5. After a few minutes, ask the women to find a new partner and to switch roles (the mirror becomes an actor, the actor becomes a mirror)

6. Repeat several times.

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












When Volunteers teach Mothers’ Groups:1. The Volunteer takes attendance.

35 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 health officer, CHA or Volunteer.

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2. Volunteer asks about new births, pregnancies or illnesses in the families of the mothers attending and help refer those with severe illness to the local health facility.






? What signs do you (or your does your wife) look for to know it is time to start breastfeeding an infant?

? How do you (or does your wife) attach the infant to the breast? What are the steps?

? Have you (or your wife) experienced problems breastfeeding? Tell me about it.

Ask the first question to hear the participant’s practices related to the best times to start breastfeeding. (Listen for the hunger cues mentioned in the lesson).

Ask the second question to hear the participants’ knowledge and practices related to good attachment.

Ask the last question to hear the participants’ breastfeeding problems. Refer to these troubles again later in the lesson and work with the group to help find solutions.


Breastfeeding Day and Night ─ 10 minutes


Ask the caregivers to describe what they see in the picture on page 28. Read the captions on the flipchart out loud. Share the meaning of each picture using flipchart pages 27 and 28.

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Breastfeed day and night whenever the infant shows signs of hunger. Hunger signs include sucking the thumb and fingers, sticking the

tongue in and out of the mouth and moving the head from side to side.

Do not wait until the child cries. Breastfeed at the first signs of hunger.

Breastfeed on one breast until the child pulls away and is satisfied. If he is still hungry, offer the other breast until he is full. Breastfeed at least ten times a day (including the night).

? What signs does your child make when he is hungry?? How do you know when it is time to switch breasts?

Additional Information for the TrainerInfant Hunger Some infants are hungrier on certain days than others. If the infant shows

increased hunger, breastfeed more often. After two days of additional breastfeeding, the mother’s milk supply grows to

meet the child’s needs. Breastfeeding and New Pregnancy Exclusive breastfeeding is more than 98% effective in preventing new

pregnancy as long as ALL of the four principles below are true: 1. The mother’s monthly bleeding has not started again and2. The mother gives only breast milk whenever the infant show signs of

hunger—day and night and3. The infant is allowed to empty one breast before the other breast is

offered and 4. The infant is less than six months old.

Breastfeeding and Anemia Giving only breast milk, whenever the infant shows signs of hunger, delays

the return of the mother’s monthly bleeding. This helps the mother to restore blood and iron lost during delivery. Exclusive

breastfeeding thus helps protect the mother from anemia.

Breastfeeding Positions─ 10 minutes

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Hold your infant close. Support his head and body when breastfeeding.

Hold the newborn close so your bodies rest against each other. Support the infant’s body with your arm. Keep the newborn’s head, neck and body in a straight line. Support your breast with one hand. Do not squeeze the breast. It will block the flow of milk. Look at the infant to monitor his or her feeding. Breastfeed sitting up or in bed. Choose the position which make you most comfortable.

? What position do you use to breastfeed?? What other positions can be used that still support the infant.

Additional Information for the TrainerPoor position Sucking in a poor position can cause sore and cracked nipples, unsatisfied

infants, infants that fail to grow well and swollen or “engorged” breasts.Cracked Nipples To relieve cracked nipples, rub breast milk into the cracks to keep the nipples

soft when not breastfeeding. Do not wash nipples more than once a day with soap. Soap dries out the nipple.

Engorgement When breast feedings are infrequent, delayed, or missed, or when infants are

positioned incorrectly on the breast, milk collects in the breast and puts pressure on surrounding tissue causing engorgement.

Engorgement damages the tissue and increases the risk of infection. When bacteria enter the breast through an opening in the nipple or a break in the skin, the damaged tissue may become infected.

Breast Infections (Mastitis) A breast swelling (blocked duct) does not usually develop into an infection if

the mother increases breastfeeding.

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Even if the mother has an infection, she can continue breastfeeding while taking antibiotic treatment for the infection.

Good Attachment ─ 10 minutes




Wait until the infant’s mouth is wide open, before bringing him to your breast.

Touch the infant’s lip with your nipple. This causes the infant to open his mouth. Wait until the infant opens his mouth very wide. Bring the infant to the breast. His mouth should cover most of the darkened part of the breast. The infant’s chin should physically touch the breast. The newborn’s lower and upper lip should pout out.

? What happens if the infant does not have a good attachment?

7. Activity: Attachment - 20 minutes

1. Ask a woman who has an infant younger than 6 months to demonstrate how she breastfeeds her infant (if the infant is willing to latch).

2. Ask the others in the group to look at the attachment and position of the mother.

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a. Is the infant facing the mother’s body?b. Is the mother supporting the infant’s head and body with her arm?c. Is the infant’s mouth covering most of the dark area around the nipple?d. Is the infant’s lower lip curled back?e. Is the infant swallowing in large gulps? f. Does the infant have to reach or turn his head to reach the nipple?

3. Ask others to demonstrate different positions that they use to breastfeed. Evaluate each position to make sure the infant is supported and has good attachment.

? What difficulties have you experienced breastfeeding?

4. Together try to solve problems mentioned by the mothers. Encourage mothers with more experience to share their wisdom with younger mothers.

5. Encourage all mothers to continue exclusively breastfeeding infants until six months of age.





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For example: I will wait (or encourage my wife to wait) until the infant opens his mouth

wide before bringing the infant to the breast. I will support (or encourage my wife to support) the infant’s head while

breastfeeding. I will breast feed (or encourage my wife) to breastfeed during the day

and night whenever the infant shows signs of hunger. I will breastfeed (or encourage my wife to breastfeed) at the first signs of

hunger, not waiting until the infant begins to cry.

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Lesson 7: Encouraging Mothers to Breastfeed

Family members will encourage mothers to give only breast milk to newborns and whenever the infant shows signs of hunger for the first six months of life.

Family members will not offer butter, animal milk or any other food or liquid to infants for the first six months of life.

Family members will believe that the first yellow milk and colostrum will satisfy and meet the needs of the infant for the first six months of life (increased action efficacy).36

This lesson is for the teaching of grandmothers, fathers and other influential family members. Adapt the lesson as needed removing games, attendance and other sections which may not be appropriate when reaching grandmothers, fathers or other influential family members.

Materials: 1. Attendance Register 2. Flipchart3. Three rocks or other objects for the Belly Ball Activity (see lesson 5)*

Summary:All of the activities below should be included in the lesson whether one is training a CHA, a Volunteer or a Mother Group. Game: The Knot Attendance and Troubleshooting Ask about Current Practices Share the meaning of each picture using flipchart pages 33-34 Activity: Belly Balls Discuss Barriers Practice and Coaching in pairs Request Commitments

1. Game: The Knot ─ 10 minutes

36 Perceived action efficacy is a behavioral determinant in barrier analysis: if caregivers really believe that breastmilk and colostrum will satisfy the infant’s thirst and hunger for the first six months (it really works), they will be more likely to practice it.

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1. Ask the participants to stand in a circle, with shoulders touching. 2. Each participant grabs the hand of another participant in the circle (not

someone standing next to them). 3. Then with the other hand, they grab the hand of a different participant in the

circle (again not someone standing next to them and not both hands of the SAME person).

4. After each participant is holding hands with two different people, ask the participants to “untie” the knot.

5. They cannot let go of the hands they are holding. They can lift arms over shoulders, and step over clasped hands. Encourage them to work together to untangle. (It takes time, but can almost always be untangled).

6. They should finish with one single circle (some may be facing out rather than in).

After the game, ask:

? What can we learn from this game?o We need each other to solve problems. o We need everyone to agree and help each other.o Persistence will help us to solve the problems we face!

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








not to follow your commitments? Tell the story of what happened?

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o What factors (people, events or chores) in your life made it difficult to keep your commitments?











? What did you advise your family members to give newborns to eat or drink at birth? Why?

? What is the purpose of inger? When should it be given? Why?

? What is the best age to begin offering water, butter, porridge or other foods and liquids (excluding breast milk) to infants?

Ask the first question to hear the participants’ knowledge and practices around immediate breastfeeding.

Ask the second question to hear the participants’ ideas about the use of colostrum (inger).

Ask the last question to hear their opinions about the timing for other foods and liquids.


37 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 Health Officer, CHA or Volunteer.

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Encourage Breastfeeding for the First Six Months of Life - 10 minutes




Breast milk is the best food and drink for infants. Let the newborn to breastfeed immediately after birth. Encourage the mother to breastfeed whenever the child shows signs

of hunger.

Do not offer butter, animal milk, coffee, tea38, or any other foods or liquids for the first six months of life.

Advise against offering butter or other drinks/fluids for the newborn before six months of age.

Encourage exclusive breast feeding of the newborn until six months of age.

Make sure that the lactating woman takes two more meals (additional foods) each day.

Encourage her to return within 2 days39 of giving birth for a checkup.

? What should the husband, grandparent and other family members do for the mother after she gives birth?

? Should a pregnant or breastfeeding woman fast? How do you think this impacts the growth of the child?40

? What taboos or customs make it difficult for women to follow these practices? How can we overcome these obstacles?

Additional Information for the Trainer38 Coffee and tea have been added to foods forbidden for infants in the first six months of life. 39 The flipchart incorrectly says three days. It should say two days. 40 The last two questions are new and have been added in the lesson plan (they are not in the flipchart).

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Review the additional information in lessons 3, 5 and 6 before teaching this lesson.

5. Activity: Belly Balls- 20 minutes

1. Repeat the activity from 5 with the fathers, grandmothers or other influential family members.






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When the Volunteer is teaching the family members, ask each family member to discuss the things they have learned with the person sitting next to them. They will review the new teachings verbally, in pairs. The Volunteer can watch, correct and help clarify misunderstandings with each pair.




For example: I will encourage my wife (or family member) not to give butter, water or

any other foods or liquids to my child at birth, only breast milk. I will encourage my wife (or family member) to offer only breast milk for

the first six months of life. I will help my wife (or family member) return within two days of giving

birth to the health facility for a checkup.

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Lessons 1-7 Pre and Posttest

Two questions from each lesson are listed below for lessons 1-6. Only one question is listed for lesson 7 since the lesson is very short. Before and after teaching the materials to staff and trainers, give the posttest to evaluate their understanding. For those who score less than 75% (those who miss more than 3 answers), give them more training to help them grasp the key content.

1. What is the goal of the cascade group program? Circle only one answer.

A) To increase the income of families including mothers and children. B) To provide food and medicine for mothers and their children.C) To encourage mothers and children to read and write. D) To reduce malnutrition of pregnant mothers and their children under two years of age.

2. How often will Mother Groups meet with the Volunteers (and Volunteers meet with CHAs)?

A) They will meet once or twice a month. B) They will meet once a week. C) They will meet once every two months. D) They will meet once every six months.

3. After greeting everyone, what is the first activity the facilitator will lead?

4. What is the last activity the facilitator will lead at the end of the lesson (after discussing barriers and helping participants find solutions to these barriers)?

5. Pregnant women should visit the health center at least how many times? _______________________.

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6. Pregnant and lactating women should do all of the following except ONE. Choose the answer which is not correct (should not be followed during pregnancy).

A) Eat one additional meal (or two small snacks between meals).B) Continue eating the same amount of foods that you eat normally. C) Sleep under a mosquito net each night.D) Eat foods with a sprinkle of iodized salt each day.

7. Which of the following are signs of anemia (weak blood)?

A) Skin rash and feverB) A cough that lasts more than 30 days. C) The tongue, and inside of the lips and eyelids are pale. D) Vomiting

8. Name two things pregnant women can do to prevent anemia.

a. _______________________b. _______________________

9. True or False. The best food to give newborns is butter.

10. Which of the following things should be given to a child at birth? Choose one answer.

A) Breastmilk onlyB) Water and breastmilk only C) Animal milk, water and breastmilk onlyD) Porridge, animal milk, water and breastmilk

11. Name two benefits (for infants) of offering only breastmilk for the first six months of life?

a. _______________________b. _______________________

12. All of the following describe good attachment of a newborn to the breast except one. Circle the answer that does NOT describe good attachment.

A) The newborn’s mouth covers most of the darkened part of the breast.B) The newborn’s chin physically touches the breast.C) The mother pushes the nipple into the newborn’s mouth. D) The newborn’s lower and upper lip pouts out.

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13. What can the family do to support a mother after delivery? All of the following are good answer except one. Circle the answer that is NOT a good practice.

A) Help her to find transportation back to the health center within two days of giving birth. B) Encourage the mother not to give butter, water or any other foods or liquids besides breastmilk for the first six months of life. C) Help the mother to eat two additional snacks each day while breastfeeding to maintain her health.D) Encourage her to wait for the child to cry before beginning to breastfeed.

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Lessons 1-7 Pre and Posttest ANSWERS

Two questions from each lesson are listed below. Before and after teaching the materials to staff and trainers, give the posttest to evaluate their understanding. For those who score less than 75% (those who miss more than 3 answers), give them more training to help them grasp the key content.

1. What is the goal of the cascade group program?D) To reduce malnutrition of pregnant mothers and their children under two years of age.

2. How often will Mother Groups meet with the Volunteers (and Volunteers meet with CHAs)?

A) They will meet once or twice a month.

3. After greeting everyone, what is the first activity the facilitator will lead?

They will lead a game. 4. What is the last activity the facilitator will lead at the end of the lesson (after discussing barriers and helping participants find solutions to these barriers)?

They will ask each CHA, Volunteer or mother to make a commitment to try one of the practices he or she has learned during the lesson in the next two weeks.

5. Pregnant women should visit the health center at least how many times?

At least four times.

6. Pregnant and lactating women should do all of the following except ONE. Choose the answer which is not correct (should not be followed during pregnancy).

B) Continue eating the same amount of foods that you eat normally.

7. Which of the following are signs of anemia (weak blood)?

C) The tongue, and inside of the lips and eyelids are pale.

8. Name two things pregnant women can do to prevent anemia.Any two of the following things are correct: Sleeping under a mosquito net each night Taking iron pills each day

Eating organ meat, fish or red meat.

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Getting treated for worms (not mentioned in the training but also true).

9. True or False. The best food to give newborns is butter. FALSE. The best food is the mother’s first yellow milk.

10. Which of the following things should be given to a child at birth? Choose one answer.

A) Breastmilk only

11. Name two benefits (for infants) of offering only breastmilk for the first six months of life?

Any two of the following things are correct: The mother’s breastmilk protects the children from disease The mother’s breastmilk is the most nutritious food available it is

specifically designed to meet the needs of infants. The mother’s breastmilk satisfies the infants hunger and thirst. The mother’s breastmilk will not cause diarrhea or sickness like other

foods and liquids would.

12. All of the following describe good attachment of a newborn to the breast except one. Circle the answer that does NOT describe good attachment.

C) The mother pushes the nipple into the newborn’s mouth.

13. What can the family do to support a mother after delivery? All of the following are good answer except one. Circle the answer that is NOT a good practice.

D) Encourage her to wait for the child to cry before beginning to breastfeed.

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