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Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills. Geneva: World Health Organization; 2013.

Counselling for Maternal and Newborn Health Care: A Handbook for Building Skills.
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What is in this session?
The focus here is on how to counsel and communicate with women about care in the home during pregnancy, also called self-care.
What skills will I develop?
- Two-way communication: communicating with groups
- Forming an alliance: facilitating partner and family involvement
- Counselling context: providing support to household decision-making processes
- Addressing socio-cultural beliefs and practices.

What am I going to learn?
By the end of this session you should be able to:
- Counsel and communicate effectively with women on self-care in the home during pregnancy.
- Consider cultural and religious beliefs in the community affecting the care a pregnant woman receives in the home and the support she receives from her partner and family.
- Assess how to involve partners and other key family members in counselling.
- Consider household decision-making dynamics.
General management and care during pregnancy
This topic is about the care a woman during pregnancy needs to receive in the home – focusing on pregnant women who do not appear to have problems or complications. This session seeks to address the following questions: How should you as a health worker support women in taking better care of themselves during pregnancy? How can their partners, their families and the broader community support and care for pregnant women? How can cultural practices affect the care a pregnant woman needs and recieves?
Not all topics require counselling; some are points of communication and discussion - others require a more in-depth process to determine how women will take better care of themselves with support from their families. Limited time and resources mean it is not always possible to counsel all women in all aspects of care during pregnancy. Learn to identify with each woman which points should be prioritized and how to best respond to the individual needs of each woman. Find a balance between general communication and the need to provide specific counselling and support to individual women.
WHO RECOMMENDATIONS FOR SELF-CARE DURING PREGNANCY
- Visit your health centre at least four times during your pregnancy, even if you do not have any problems.
- If you have any concerns about your health or your baby's health, go to the health centre.
- Bring your home-based maternal record to every visit.
- Eat healthier foods including more fruits and vegetables, beans, meat, fish, eggs, cheese, milk.
- Take iron tablets and any other supplements or medicines you have been given every day as explained by your health worker.
- Rest when you can. Avoid lifting heavy objects.
- Sleep under a bednet treated with insecticide.
- Do not take any medication unless prescribed by the health centre.
- Do not drink alcohol or smoke.
- Practise safe sex, including use of a condom correctly in every sex act to prevent STIs or HIV/AIDS, if you or your partner is at risk of infection.
- Know the signs of labour – painful contractions every 20 minutes or less; bag of waters break; bloody sticky discharge.
- Know the danger signs and when to seek care (see Sessions 7 and 8).
Activity 1
1 to 2 hours
To help you prioritize aspects of self-care for counselling and communication with women and their families.
Part 1: This part of the activity encourages you to reflect on what you already know about care in the household of pregnant women in your community.
- What are the general practices for care of the pregnant women in your community? Consider religious and socio-cultural practices, including sexual practices and taboos, and topics such as nutrition, hygiene, rest, work, vaccinations, medicines and supplements. (Refer to the work you have done in Session 4, Activity 1 on local practices).
- Are most women in your community seen by a health worker for antenatal care? How many times do they receive care during pregnancy, and in what months of the pregnancy do they receive care?
- For those who do not receive antenatal care, why not? How can they be supported so that they would receive care? What can you do to support them? What can others, including the family and the community, do?
- What things can a woman do for herself to maintain a healthy pregnancy?
- Are most women aware of the changes that will happen to their body during pregnancy?
- Are there any harmful local practices during pregnancy? (See Session 4)
- What is the role of the partner during pregnancy? Who makes decisions in the household related to how a woman should be cared for during pregnancy? Are these decisions supportive? How could you talk to families about the decisions they make, and help them to consider the consequences of them?
- How can you consider socio-cultural and religious practices when counselling and communicating on self-care of women during pregnancy?
- Refer to the above list “WHO recommendations for self-care during pregnancy”. How do the WHO recommendations compare to the advice and information you routinely give women on general care during pregnancy?
Part 2: This part of the activity aims to help you prioritize the most important information that needs to be communicated to women and other family members.
- Review all the information that you have on the general care and management of pregnant women: nutrition, hygiene, physical activity, vaccinations and preventing diseases and infections. Any other topics to add? Think how you can best use this list.
- When are the best times during pregnancy to communicate and counsel women on the different topics?
- Consider which points are best for communication and which need more interaction or a counselling process. Consider where you can be the facilitator or where other resources or people can be used.
- Which information should be shared with her partner and other family members; consider the importance of different family members and their roles during pregnancy: the pregnant woman, her partner, her mother, her mother-in-law, other women, and elders.
- Consider if there are women in the community with special needs who may require additional information or support for care during pregnancy (i.e. adolescents, women with HIV, women with a handicap, and women who live with violence. (See Sessions 14 and 16)
Our View
Considering the local context, develop a list of key points on self-care during pregnancy and use it during your interactions with women to review key information. If no other material exists, give your list out to women and their families. You could also use it as a guide when discussing with groups in the community, women, or with family members. It is as important to talk to families and partners as it is to talk to women about self-care during pregnancy because they play an essential role in support and care of the pregnant woman and are often the key decision-makers. They need to be aware of their role.
It is also important to consider the beliefs and practices that exist in your community which might have an effect on self-care, or make it difficult for women or their families to better care for the woman in the home. Some women may need more counselling than others to help them follow the recommendations on self-care. Consider each woman and her needs individually, and how you can best support her.
Communicating to groups
Care in the home of women during pregnancy is perhaps the most suitable topic for group discussions. This is because the topic does not have to be personalized as it is not about specific situations or individuals. As well as discussing general care issues with community groups, encourage them, particularly groups of women, to discuss these issues among themselves. By sharing their experiences women can support each other in identifying feasible solutions to problems they face. It is also a source of comfort to hear that other women have been through similar experiences.

Encourage women to share their experiences with one another
Sometimes group discussions surrounding antenatal care are carried out in a very authoritarian manner with little or no participation from the group. A health worker stands in front of the group and tells them the things they should do, without considering the local context or finding out what women already know and do, or without letting the group discuss and ask questions. With groups, your role is to be a facilitator using the core principles outlined in the counselling process (refer to Session 2).
To be a facilitator means to promote participation so that all the skills and knowledge of the group members are used. In other words, everyone should have the opportunity to participate and contribute to the discussion. The facilitator needs to show warmth and empathy to encourage group members to interact. You can also work with groups in other ways, for example, by breaking up into pairs or small groups to discuss issues before presenting back to the wider group. Alternatively you could use a ‘brainstorm’ technique whereby people provide different ideas to be discussed or where you make a list with the group about what they already know and practise. Remember to have them consider the information you are presenting with the local practices, customs and traditions in mind. Together you should discuss how they differ, share points of view and work towards finding a solution that ensures the health of pregnant women.
Another approach might be having educational material or an image such as posters or flipcharts to serve as prompts and help initiate a discussion.
Although working in groups can be helpful, especially if time or resources are scarce, you must still be aware of individual needs. It is possible to create a supportive environment for problem-solving within a group, but some women's problems will need your individual attention. Thus in the individual antenatal care session with the woman, the different points can be summarized and you can determine with her which points require more discussion and/or counselling.
REMINDER
With time and practise you can find ways to help people actively participate in group discussions. For example, you can help to relax the group by getting everyone to say something easy to begin with to get used to the idea of talking, like getting them to introduce themselves and say when their baby is due.
Activity 2
90 minutes
To help you prioritize aspects of self-care for counselling and communication with women and their families.
This activity builds on Session 5 Activity 4 where you were observed facilitating a group. This activity provides you with another opportunity to practise your group facilitation skills, but in addition, helps you to practise communicating to partners and families about their role in ensuring the pregnant woman has the care she needs in the home. Review the activity and notes in Session 5 and your own notes, as well as the material in this session before completing this activity.
- Plan in advance a group work session with partners and family members of pregnant women to discuss the needs of the woman during pregnancy.
- Ask colleagues to watch and act as observers.
- Conduct the session.
- Following the session, ask for feedback from the group participants using the following questions (or it may preferable for one of your colleagues to get the feedback from the group, so that participants feel free to answer).
- Were you able to say what you felt?
- Were you given an opportunity to ask questions?
- Were you able to share your knowledge with the group?
- Did you disagree with anything the health worker had to say? Were you able to express this disagreement easily?
- Did you still have questions that are unanswered or points you would like clarified? What are they?
- Did you feel that the facilitator allowed everyone to participate? How did she do this?
- Was the session interesting? Why or why not?
- What do you think could have been done better?
- Following the session, use the following checklist with your observers and yourself (in addition to the questions above):
- Was the information you provided clear?
- Were you aware of the groups' interactions?
- Did you only give information or did you allow for discussions?
- How did you handle people's questions?
- How did you handle opposing point of views?
- Did you facilitate the identification of problems and solutions?
- What did you do well and what do you need to improve?
- How will you go about improving these skills?
Our View
Facilitating a group session is a skill you can learn with practise. In a group session, you need to ensure that everyone has the chance to share their knowledge, express their questions and concerns, and to participate in identifying problems and solutions. But at the same time you need to lead the group and make sure that questions or other information which you may not agree with is explored and discussed. At times, when appropriate you need to be directive, for example, if one person is talking over another, dominating the discussion or not sticking to the key points of the discussion. However, you also need to find a balance; sometimes people want to bring in other issues which are relevant for their situation. Each group you facilitate will be different because people have different needs, knowledge and beliefs; your skill lies in being able to bring these into the discussion and in being able to establish an atmosphere of trust where everyone feels they can talk and participate freely.
What did I learn?

In this session you have reviewed the information to be communicated to women and their families about self-care during pregnancy. You have considered how to communicate in groups, and how to encourage sharing and discussion of common problems and their solutions.
Now take some time to reflect on what you have learned in this session. Which skills do you want to strengthen or develop further? Plan some time to practise them. You might like to think about how you can involve partners and families more in the counselling process, and how in particular you can get them to be more involved with the general care of women during pregnancy. Use your notebook to write down your group work skills and to reflect on how to improve these. You could also consider making some notes on how you might be able to identify those women who will benefit more from additional one-to-one counselling. These may be women with high-risk pregnancies, women with special needs such as adolescents, women with multiple pregnancies, women with disabilities or women who show signs of abuse. Some of the other sessions in this Handbook will help you to identify these women (refer to Sessions 2 and 16).
- GENERAL CARE IN THE HOME DURING PREGNANCY - Counselling for Maternal and Newborn...GENERAL CARE IN THE HOME DURING PREGNANCY - Counselling for Maternal and Newborn Health Care
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