What is in this session?
This session focuses on some of the different factors that can affect or influence counselling for MNH. These include the larger social and cultural context, including socio-economic conditions, cultural and social norms, gender roles, and household decision-making processes.
These diverse factors will impact upon your counselling session; therefore a deeper understanding of their influence is required. This session also considers specific situations such as couple counselling, and counselling on sensitive issues such as sexuality.
What am I going to learn?
By the end of this session you should be able to:
Explain the key contextual factors which have an impact on counselling for maternal and newborn health.
Analyse the effect these factors may have on the counselling relationship.
Explain the importance of couple counselling and counselling on sensitive issues.
The counselling context
The term ‘counselling context’ does not refer here to the physical location where counselling takes place (which we call the counselling environment) but relates to the social, cultural, economic, religious and political factors of the place where you work, and the communities in which the people you will counsel, live. This section examines how these different factors may influence the counselling context.
It is important for you to be aware of the different factors that have an effect on the counselling context within the community you work. In the previous sessions we highlighted how important it is to assess and understand the woman's own knowledge, skills and individual situation. It is also important to assess and understand the wider cultural and social context in which you work.
Economic conditions
Economic status refers to one's financial status and is strongly related to health and educational status. So in general, most people with a low economic status (e.g. a low income) are also likely to have a lower educational and health status.
On the other hand, those with a higher economic/financial status will have better access to education and health services and will have higher status in these areas. It is important to take into account the socio-economic status of a woman, couple or family because this status will affect the decisions they have to make as well as the needs they have. For example, a woman who is poor may not have money to attend a health facility (either for child care, transport or where she must pay user fees). Similarly if a woman has a low educational status she may not appreciate the benefits of birth in a health facility and her low health status may mean she is at higher risk of poor health outcomes for both her and her baby. Educational status is also related to literacy. You need to know the literacy level of people that you counsel so that you do not give them complex advice or instructions in words which are unfamiliar to them, materials that they cannot read, or forms which they are unable to understand or complete.
UNDERSTANDING A WOMAN's SOCIO-ECONOMIC SITUATION
Be aware that this may be a sensitive topic for some women.
Try open-ended questions as you try to form an alliance:
“I'd like to get to know you a little more; perhaps you can tell me something about yourself and your home situation?”
At other times you will have to be more direct e.g. “What level of education did you finish?”
How does your household earn its income?”
It can help you to form an alliance with the woman if you are open with her about why you want to know this information. Tell her that knowing this type of information will help you to tailor the service you provide to her specific needs.
Social and cultural context
Culture is a term we use to describe the values, beliefs, practices and ways in which a community or society lives. It also includes the way the people express themselves, communicate, and interact with one another. The social context refers to how people are organized, in terms of family groupings (do they live in extended or nuclear /traditional families? or do husbands have several wives?) It also refers to group interactions and hierarchies within communities. For example, are there group leaders, chiefs, or headmen or women, and what role do they play? The cultural and social context affects all aspects of life, from how people greet one another, to how they interact in the household and how they make decisions.
REMINDER
Being aware of the social and cultural context will help you form an alliance with the woman or couple you are counselling and will help you decide appropriate ways to communicate in terms of how you ask questions, how you approach sensitive issues, and how you facilitate the process of problem-solving. It will also enable you to tailor your counselling to their specific needs.
Issues such as religion or social status affect peoples' ideas or feelings and this can influence communication and counselling. The cultural and social context can be expressed differently depending on the setting such as the home, schools, the workplace, or the health service. Your professional training took place within a particular perspective on health and you may feel it is the most appropriate way of approaching health issues. Other communities and cultures have their own ways of talking about health which may be different from yours. Thus it is important to reflect on what these different beliefs and values are, as they will have an impact on the way in which you interact with women and their families and the way they interact with you.
Pregnancy and birth are normally very social and cultural events and thus tied to many specific beliefs and practices. In order to better support a pregnant woman and her family, it is important to know these beliefs and practices. Some may be very good for the woman and her baby, others may not be beneficial but also do no harm; you can build upon these beliefs and practices, and try to incorporate them into your practice and service. Other beliefs and practices may cause harm. You will need to discuss these with the women and her family and the broader community to see how they can be changed.
Activity 1
1 to 2 hours
To assess whether local practices in your community are helpful, harmful or harmless for maternal and newborn health.
Note to facilitator: You can divide the group into 3 smaller groups and have each group look at a different aspects, e.g., one group looks at antenatal, another group looks at childbirth and the third group looks at postnatal practices. Then bring them back together as one larger group to discuss their findings.
Within different cultures or social systems there can be ceremonies or ways to mark important events such as childbirth. For example, pregnant women may be expected to act or behave in certain ways. They may be given medicines or special foods. There may be ceremonies or activities to mark the arrival of the new baby, or practices carried out during labour and birth.
Understanding the context in which you are working and counselling is very important. This activity looks at local practices to help you to assess some important aspects of your context. Consider talking to women and community groups to help you answer these questions.
Write down in your notebook all the local practices and beliefs that you have come across regarding pregnancy, childbirth and the postpartum/postnatal period. Ask women or groups if there are any other practices and beliefs you should add.
For each one of the practices you have identified, consider whether it is good for the health of the woman and/or baby, if it is harmless or harmful. Organize your list of practices under the three headings:
You may need to find out more information to be able to make your classification. A helpful practice is one that supports the advice and information that you give to women (for example, exclusive breastfeeding), a harmless practice is one that does not contribute to improving the health status of the mother or newborn but also does not have a damaging effect (for example, beliefs/rituals surrounding the care of the placenta after birth). Harmful practices cover anything which might carry a risk of infection, loss of blood, transmission of an STI or make the mother or newborn weak. Harmful practices may also delay the woman's access to appropriate care (for example, beliefs that announcing the onset of labour will result in an evil spell being cast). The following questions may help you as you think about this.
Does the practice involve animal or human waste? For example, a common practice of rubbing manure onto the baby's umbilical cord can cause dangerous infections.
Does the practice involve allocating different amounts of food, work or rest? For example, some cultures routinely give women less to eat than men. This could be potentially harmful to a pregnant or breastfeeding woman. But a cultural practice which encourages a woman who recently gave birth to rest in bed can be helpful.
Does the practice involve sexual intercourse? For example, sexual cleansing where a woman with STIs has sex with a traditional medicine practitioner is unlikely to do any good, and can transmit STIs/HIV if condoms are not used. However, sexual intercourse between a woman and her husband during pregnancy is harmless, unless one or both of the couple are HIV-positive and are not using condoms.
Does the practice involve taking blood from the woman outside of the health service? For example, taking blood from pregnant women to cleanse her of demons could be harmful as there is risk of infection and too much blood could be taken.
Does the practice involve local herbs, remedies or medications? For example, taking local remedies to stimulate contractions could be harmful, but other herbs or foods to promote better nutrition might be harmless or helpful depending on the ingredients.
Does the practice involve delays in reaching a skilled attendant? For example, the belief that infidelity causes obstructed labour may result in reluctance to give birth in a health facility.
Think about how you might incorporate some of the helpful and harmless practices into your advice and counselling with pregnant women and their families. Think about how you will discuss the harmful practices with women, their partners and their families and the community so you can improve your mutual understanding.
Our View
Your list will be divided into those practices which are helpful, for example, a pregnant woman should be given an additional portion of meat or fish to help her stay strong. They could be harmless practices, such as the placenta after birth should be buried. Or they could be harmful, such as putting cow dung on the umbilical cord. Whether helpful, harmless or harmful, you should try to better understand the practice and belief. Where practices are helpful, they should be encouraged. Where harmless, there is no point in discouraging them. You may find you get more respect and better support from the community if you respect their harmless practices which may have great significance to them and their cultural and social context.
Discuss with women, their families and others in the community those practices which are harmful or which could endanger the health of the mother or newborn. Listen to their explanations about the practice and discuss the reasons why the practice is harmful. In many situations a replacement harmless practice can be substituted, instead of the harmful practice. In the case of female genital mutilation, for example, you could still conduct a “passage of rites” ceremony but simply replace the words in the traditional song used during the ceremony and provide a beaded necklace or some culturally suitable symbol instead of performing the cutting ceremony.
REMINDER
Many practices are deep rooted in social and cultural norms and gender roles and perceptions. However, health workers can play an important role in stimulating discussions on these issues in the community.
Gender roles
Two of the differences between men and women are sex and gender. Sex is the physical, biological difference between women and men. It refers to whether people are born female or male. Gender, is not physical like sex. Gender refers to the expectations people have from someone or a community because they are female or male. Gender attitudes and behaviours are learned and the concept can change over time. Sex is biologically determined while gender is socially determined in terms of the roles and responsibilities that society or family assigns to women and men.
Men and women usually accept the roles defined and perpetuated by their community which can have both advantages and disadvantages for them. There are many factors that influence gender roles. These include: age, culture, marital status, education, economics, profession, and the country or society itself. Understanding the gender roles in the community can help you to better understand the situation of the women and men you counsel, and thus improve your counselling interactions.
EXAMPLES OF GENDER ROLES
Women should stay at home and look after the home or family.
Men should not do housework.
Men should not cry.
Women should not disagree with their husbands.
Women should keep their bodies covered.
Women should not drink alcohol.
How are women and men expected to think, feel and act in your community? How do they learn to do this? Gender roles are learned from a young age as parents may treat girls and boys differently. In addition, children often copy the behaviour of their parents.
Many women find the gender role of wife, mother and housekeeper very satisfying, providing them with status in the community. However, it can be a disadvantage to other women who want to have only a few children or want to pursue a career or other interests. Some women manage to combine a number of different roles. For the family and the community it can be beneficial for women to look after the children and remain at home, but it could also be a disadvantage as women who have paid employment could bring other benefits to the family and community.
Gender roles also teach men and women to express themselves differently. Women are often allowed to be more emotional whereas men are taught to keep their feelings inside. Men may get less support when they have problems due to expected gender roles. Sometimes it will be important for you to counsel men and it will be particularly important to take into account the community's norms for gender roles as you do so. For example, a woman may want her partner or husband to be present when she gives birth but the man may feel pressure from others in the community or fear the reaction of others in a community where this is not usual practice.
Similarly we can see examples of gender roles in the community. In some communities the opinions of men may be valued more highly than women's opinions. Women may not be encouraged to speak or participate in discussions. This means that the community hears more about what men think about problems and issues. The community or family may not benefit in this situation as women's knowledge and experience are undervalued or overlooked. You may need to be aware of this when you work with communities, in order to support women to share information, and discuss their knowledge.
EXAMPLES OF GENDER INEQUALITIES
Women make up two-thirds of the illiterate population in the world, and in many countries, there exists a gender gap in education - far fewer women than men are educated.
Women carry out two-thirds of the world's work, but earn only one-tenth of the world's income.
Maternal mortality in developing countries is 22 times greater as an average than in developed countries.
In many places, women are twice as likely to work for nothing as men.
Think about these statements. You may like to use them as a discussion point with the community when you discuss gender roles and inequality.
Source:
Population Council. A client-centered approach to reproductive health. A trainer's manual. Islamabad, Pakistan: 2005. .
The impact of gender roles on health
Gender roles have an impact on beliefs, attitudes and values. Gender roles can also greatly affect health behaviour and the sexual and reproductive health of men and women in your community. For example, in some communities adolescents are encouraged to have sex with older men; thus gender roles can effect the transmission of STIs including HIV/AIDS and can also lead to unwanted pregnancies. Gender roles can lead to other undesirable sexual behaviours such as women having sex when they do not want to, and even rape and violence against women. Alternatively gender roles may prohibit women from expressing their own sexual needs or desires. Gender roles can have an impact on decision-making. For example, in some societies where there is a female hierarchy, young mothers will not be allowed to take decisions about seeking care on their own. This may not always be negative. In certain cases, adolescent girls may want support from older women in taking decisions.
Household decision-making processes
People do not make decisions in isolation from the context of their lives, and this includes asking advice from other family members and even the wider community. Research has shown that both the context in which decision-making occurs and the social influences such as those of a partner or the family, often have more effect on decision-making than merely information and education or the provision of communication materials.
You may need to facilitate the decision-making process among all those in the household who have important contributions to make. Cultural practices and gender roles often heavily influence the decision-making process. A woman may be unwilling to commit to a plan of action or take a decision until she has discussed the issues with her partner or other family members such as her mother or mother-in-law. You can support women in these discussions by reviewing the advantages and disadvantages of different options and her needs in that situation.
AN EXAMPLE OF COUNSELLING WITHIN THE CONTEXT OF HOUSEHOLD DECISION-MAKING
Situation: Counselling a woman about the need to exclusively breastfeed her baby up to six months.
Problem: Her mother is encouraging her to introduce porridge at three months.
Process:
Establish with the woman what she wants to do through open questioning and active listening.
Review the advantages and disadvantages with her to help her make her decision.
If she wants to continue breastfeeding exclusively then facilitate the process of generating options of how she can address this subject with her mother. She might want information from you to give to her mother; she may want her mother to join you in a discussion; she may want to practise different scenarios with you.
Activity 2
45 minutes
To assess how gender roles and household decision-making contribute to the health of the women you see.
This activity explores the context of gender roles and household decision-making and how these impact on maternal and newborn health.
Note to facilitator: consider splitting the group up into smaller groups and give them different parts of the activity to complete, which they can then share with the whole group.
Are there different ways in which women and men are expected to behave in the community?
Do these different patterns of behaviour depend on the age or marital status of women?
What impact might these behaviours have on MNH?
What other reproductive health problems might these roles contribute to?
What can you as a health worker do, in a counselling session or during your interactions with the community, to have an impact on gender roles so that women can better care for themselves and their babies?
In general, in your community, how are decisions in the household made regarding the care of a pregnant woman?
How does this affect MNH?
How might you support women in the decision-making process in their homes about MNH?
How might you include other key family or community members in the counselling and decision-making processes?
Our View
Some gender roles are influenced by religious beliefs while other gender roles are based on traditions or culture. Social norms and gender roles can lead to women not valuing their own bodies, or not understanding how their bodies work. This means they do not know what to expect or what is “normal”. Sometimes gender roles can lead to women paying more attention to the sexual needs and desires of men than to their own needs. This can lead to unwanted sex or having sex by force or to women not using contraceptives because of pressure from men. Other reproductive health problems may arise such as STIs.
You can play an important role in teaching women about the different parts of their bodies and the role that they play in sex and reproduction. Discuss with women what is normal (for example, routine vaginal discharge) and when they need to seek care (in cases of abnormal or infected vaginal discharge). You can also support women to take more control over their lives so that they can negotiate safer sex practices and contraception and participate in decision-making, especially where it concerns their sexual health, or the health of their baby.
Some communities have negative views about women's bodies. For individual women this can lead to feelings of shame and a lack of knowledge of their own body. Problems can arise because:
Help women to understand how their bodies work in relation to sexual and reproductive health. If it is socially and culturally appropriate, help them to explore their sexuality which includes their feelings and attitudes towards sexual relations.
Recognize when it is important to include partners and other family members in counselling for MNH. Also support women in how to deal with family involvement in their decisions. Do this through interactive discussions with the women. Sometimes you may need to work with partners or other family members in the absence of the woman (for example, when she is too ill to take decisions on her own). Your skill is in supporting her in determining who should be involved in the decision-making process. But remember to respect confidentiality in terms of the woman's wishes.
REMINDER
Involving the partner and other family members in counselling may require additional time and resources. However, if you only counsel a woman, the decisions she makes may be overruled later by her family.
Activity 3
3-4 hours
To explore the counselling context in your community.
Before moving on to Part 3 of this Handbook where you will examine topics and practice skills, you may benefit from a more in-depth exploration of the counselling context in your community.
Note to facilitator: divide the work of this activity among the group. Get them to plan and decide who will interview each different community group (as outlined in number 1), and to agree how the interviews should be conducted and which questions to ask.
Set up interviews, meetings or informal discussions with religious leaders, traditional healers, chiefs, and political leaders, in addition to other health providers and members of the community.
Make a guide of some of the questions and topic areas you would like to discuss in advance. The topics you explore might include areas such as:
Local culture and social systems
Politics and religion
Poverty
Gender roles
Family structure and household decision-making
Women with special needs
Local beliefs and practices related to maternal and newborn health
Opinions about the health service.
Take notes of the discussion and share them with your colleagues – imagine you are trying to explain the context to someone new that has never been to your community before.
Discuss how your findings might have an impact on maternal and newborn health.
Our View
You may find that you are working with a community where the context is the same for the majority of the population. Or you might find that you work in a community where there are lots of differences; for example, a community where there is more than one dominant religion, tribe or ethnic group. Different groups in the community will view maternal and newborn health and reproductive health in different ways. It is important to understand all the different factors and views that contribute to the social and cultural context of the area where you work. Understanding the context that communities live in can help you to counsel more effectively as you will understand the context in which decisions have to be taken and how the context may affect maternal and newborn health.
With this understanding, you can better facilitate processes for women and their families to find culturally and socially acceptable solutions for their problems. By doing this they are more likely to be able to follow the action and decisions they have taken.
Couple counselling
Just as it is important to consider the household decision-making processes, there are many times during counselling for maternal and newborn health where you will need to work with couples - the woman and her partner/husband. There are some obvious instances such as counselling about family planning where you could work with a couple, but there are other times also such as when you counsel about care during pregnancy, discuss support during labour or following birth.
When counselling a couple it is important to acknowledge that they may not have the same attitudes, beliefs and values. They may not even have the same perception of the problem or need that you are discussing. They may have different educational, social and literacy levels, and this is particularly true if culture gender roles in your community do not support women's education. Therefore you cannot treat them as a couple, but rather you must tailor your counselling skills to two individuals who need to reach a mutual decision.
You may find that you want to agree or disagree more strongly with one of the couple compared to the other. This is where the principles of self-reflection, and empathy and respect come in. You need to be aware of how your own attitudes, values and beliefs (which are shaped by the cultural, socio-economic and gender context that you live in) affect the way you think. Even if you disagree with one of the couple, you must maintain your respect for that person's point of view. It is not your role to support either the man or the woman in the argument.
If you can form an alliance with both partners, it allows for a situation of trust and mutual respect. You can then follow the steps in the counselling process, making sure you give them both an equal chance to participate in the discussion. It is possible that sometimes when you counsel a couple, the situation may become heated with one person becoming abusive or aggressive. It can be a good idea in these situations to spend time with each person individually before bringing them together so that they both have a chance to talk freely. When you bring them together you can take some time to agree upon some ground rules for your discussion.
EXAMPLE OF GROUND RULES
No interrupting one another
No shouting or aggressive behaviour
Mutual respect
Consider all options before discarding them.
In deciding upon these ground rules together you also have to take into account what is appropriate socially and culturally in terms of how men and women behave.
Counselling on issues of sexuality
For most health care providers, sexuality will probably be the most difficult and challenging area of counselling during pregnancy and the postpartum period. We are all reasonably comfortable talking about STIs and family planning methods, but discussing and counselling for other sexuality issues and in particular sexual intercourse is more challenging and as a result often avoided. There are many priorities in the provision of good health care to women during pregnancy and childbirth such as preparing for the birth, learning what danger signs to look for, all aimed at reducing morbidity and mortality from pregnancy and childbirth and providing women with good care. It is easy for issues of sexuality to be put to one side. In comparison to other clinical conditions, they are not as high on the priority list for providing good care.
However, sexuality issues do contribute to anxiety for many women in pregnancy and after birth.There is often little opportunity for these anxieties to be allayed or even discussed. This is mostly due to our own limitations in discussing matters of sexuality frankly and openly. There is also a lack of evidence in this area, which means that, there is little clear guidance.
Many women will not need extensive counselling around sexuality issues. It is useful for the health care provider to give women an opportunity to discuss sexuality issues when appropriate. Giving women the opportunity to discuss sexuality can be done simply by quietly saying to a woman that if she has any problems or questions of any kind during her pregnancy or after birth, including things that she may not feel able to talk about to other people, she can discuss them with the counsellor.
We have already mentioned the importance of the cultural and social context in counselling. This is particularly important regarding sexuality issues. Most cultures and societies have well-defined attitudes about sexuality, and also well-defined ideas as to what sexual practices are acceptable. Many of these social attitudes or morals are closely linked to the religious practices within a community. Many religious texts provide clear guidance on sexuality issues during pregnancy. Counselling around sexuality issues should always start with you familiarizing yourself with the cultural and religious context and the specific information needed around the sexuality practices of each community. If you are from the community in which you are counselling then you may already be familiar with many of the local practices. If you are not from the community then this information can sometimes be learnt from other health care providers, from the elder women, or other respected people in the community. In some communities sexuality is not an open subject and even gathering information about sexual practices needs to be done respectfully and sensitively.
Different communities use different terms for sexual intercourse. For example, some communities would not be comfortable with the term ‘sexual intercourse’ or ‘sex’ and may prefer to say ‘sleeping together’. Using the same terms and names that are acceptable in a community demonstrates respect for the community and may be a useful tool to paving the way for open discussion. It would be appropriate for you to support local sexual practices that are not harmful. For example, many communities prohibit sexual intercourse at different times during pregnancy. While there is little evidence to prohibit sexual intercourse in an uncomplicated pregnancy, it would not be harmful for couples to follow their community sexual practice in this instance and therefore you can support this practice. However, it would be inappropriate for you to actively support harmful sexual practices such as Female Genital Mutilation (FGM).
Many of the questions and concerns that women have related to sexuality issues during pregnancy are related to the physiological changes of pregnancy. For example, women may think that the normal increase in vaginal discharge that happens during pregnancy (leucorrhoea) is a sign of an STI. Providing this information as well as screening and testing for STIs is important. Women are also often unprepared for the changes in their sexual desire during pregnancy. This changes as pregnancy progresses: during the first part of pregnancy when women are often feeling nauseated and sick their desire is typically reduced; in the middle part of pregnancy women often feel much better and therefore their desire returns to normal; in the last part of pregnancy women feel very uncomfortable due to the size of the baby they are carrying, they are tired and their interest in sex decreases. These changes are all related to the body processes in pregnancy and are normal. They also may vary greatly from woman to woman.
Counselling during pregnancy is limited by time and sometimes the environment may not enable you to speak to a woman about sensitive or private topics. Sometimes the barriers of language, culture or age may become a barrier between you and the woman, particularly in discussing sexuality issues. In such instances it would be appropriate for you to encourage the woman to open up perhaps to another health care provider or community leader.
In talking about sexuality issues you may encounter a situation when a woman discloses a sexual problem that you feel unable to deal with. Examples of this may be a woman who discloses abuse or incest or a couple who have a long-standing sexual dysfunction. In this situation it would be appropriate for you to seek help from another more experienced counsellor or someone with special experience in these matters.
Note for working group facilitator
The key issue is to try to prevent the working group from totally dismissing any need for counselling around sexuality issues because they have been offended by some of the suggestions in the Handbook. The role of the facilitator is to encourage the working group to voice their concerns on this topic, demonstrate that these concerns are respected and that local custom will guide the counselling. At the same time the facilitators should try to ensure that counselling around issues of sexuality is considered to be valuable and not abandoned. It is useful for the facilitator to acknowledge the importance of counselling on issues of sexuality and the potential benefits to pregnant women as outlined in the handbook and to consider that local custom and taboos, sometimes influenced by gender discrimination may be a potential barrier to providing women with important counselling.
What did I learn?
After completing this session you should be more aware of the wider context of counselling and key factors that can affect it. These include: socio-economic status, culture, gender roles, traditional practices, and the wider support and decision-making network from the partner, family and community. You have also considered how to improve your skills in couple counselling and counselling on sensitive issues around sexuality.
Progress check
Do I understand the influence gender, the socio-economic system and culture have on maternal and newborn health in my community?
How can I discuss practices and beliefs which are not harmful?
How can I discuss practices and beliefs which are harmful?
What are the different ways I can facilitate the decision-making process with couples and other family members?
How can I address sexuality concerns of women during pregnancy or after birth?
