Training Curriculum for Traditional Birth Attendants

Reproductive and Child Health Alliance Funded by USAID

Revised August 2002

Content
Subjects
Training time table Guidelines for TBA trainers List of training materials 1. Introduction 1 2 3 4 6 9 11 12 14 16 18 20 22 24 26 28 29 31 33 34 36

Page number

1a. Pre test 2. 3. 4. 5. 6. 7. 8. 9. 10. 11. 12. 13. 14. 15. 16. 17. 18. 19. 20. The role of the TBA Anatomy of the female reproductive tract Normal pregnancy Nutrition for the pregnant and breastfeeding woman Health center visit The five cleans Routine ante natal referrals and danger signs in pregnancy. Normal labour Placenta delivery and immediate care Danger signs in labour and delivery Danger signs post partum Post partum hemorrhage Post natal care How to refer a patient Breastfeeding Family planning Referral hospital visit HIV/AIDS Community work

21. 22. 23. 24.

Data collection Home Birth Kits Revision Post test

38 40 42 44

Guidelines for TBA trainers Please prepare each teaching day carefully. Ensure that the training room is comfortable and clean. Make sure that all training materials are present, that the role plays and games are prepared and that you know the content of the lesson plans. The visits to health center and referral hospital should be prepared with planning visits before the workshop starts During the lessons, please follow the lesson plans of the curriculum carefully, step by step. Avoid using technical terms. Actively involve the TBAs into the sessions, by asking questions, obtain their opinions, let them repeat the important points. Most of them have a great deal of experience and their inputs are valuable, even if they don’t always practice what we teach. Be friendly and respectful. Do not blame them for any wrong action they may have taken. If more than one trainer is teaching on a particular day, all trainers should be present for the whole day. They should assist each other, especially with group discussions, role plays and demonstrations. Good collaboration among the trainers is very important. The approximate length of each lesson is suggested on the lesson plans, but it is flexible. If you need more time, don’t rush. Then the morning-or afternoon training will have to take a bit longer. If a session is finished before the allocated time, use this spare time for revision of other lessons. The morning and afternoon training is not scheduled breaks. It is up to the trainer to decide a good opportunity for the mid-morning and mid-afternoon break.

Please observe the TBAs carefully during training. If their faces show that they don’t understand or don’t agree, please respond to this by elaborating on the issue and involving them in a discussion. If the TBAs look tired and are not following the lessons, try to respond by involving them with questions, making a joke or call a break. Enjoy this training experience! You are contributing towards better maternal and child health in your community.

Session 1:
Materials:

Introduction
Newsprint with purpose of the training, 12 time tables, 12 TBA books, 12 small pieces of paper, colored pens or pencils, tape. 1 hour Introductions, presentation, explanation, drawing

Lesson time: Training method: Lesson objective:

The TBAs know each other, the trainers and health center chief. They are aware of the training purpose, time table and house rules. .

Teaching steps: Introductions For introductions, all participants introduce themselves one by one about their names, their living place, work etc. Presentation by health center chief Presentation of training objectives House rules The health center chief gives a short talk to welcome the participants and stresses good collaboration. The trainer shows the newsprint and explains the training objectives. Discussion. The trainer explains the course house rules, such as: Every TBA should be at the training place on time every day. All TBAs should attend all sessions of this workshop. Please don’t spit or smoke in the classroom. The trainer distributes copies of the time table to the TBAs and reads each heading with them. She emphasizes the times for the morning-and afternoon sessions. She answers questions. The trainer distributes small sheets of paper and colored pencils to each TBA. She asks them to draw a picture of something to do with her work or her feelings with regard of this training course. When they have finished, each TBA shows her drawing to the group and explains it. The trainer distributes one empty TBA book to each TBA. She explains that the TBAs will get handouts on their lessons during the week. These books are to keep these handouts safely, so that they can later look at the pictures to remind themselves of the lesson content. The trainer asks the TBAs to stick the small pieces of paper with their drawings on their TBA book.

Time table

Drawings

Explanation: TBA books

Session 1a
Materials: Lesson time Method: Lesson objective:

Pre-Test
Pre-test papers for trainer 45 minutes Individual interviews The trainers have obtained base-line information on TBAs’ technical knowledge.

Explanation

The lead trainer explains that it is necessary to perform a short test on the knowledge of TBAs before the training starts. There are many questions which the TBAs will not be able to answer yet, so there is no cause for worry at all. Each trainer works with one TBA at a time. She sits with her in a quiet place where others can’t hear. She reassures the TBA and makes her comfortable. Then she asks each question from the test paper and gives the TBA enough time to consider the answer. If the TBA does not understand the question the trainer explains it, but does NOT give hints towards an answer. The trainer records the answer on the test sheet. All TBAs are to be tested in that manner.

Test

Session 2:
Materials: Lesson time: Training method: Lesson objective: Teaching steps: Small group discussion

The role of the TBA
Poster of the role of the TBA, flipchart of the TBA role, newsprint, marker pens, tape, handouts. 1 hour Discussion, explanation The TBAs are aware of their role in their community.

Explanation: the role of the TBA

The trainer tells the TBAs about the topic and purpose of this session. She divides them into three groups. Each group discusses: what is your job as TBAs? Each group uses one piece of newsprint, either writing the activities on it or drawing them. One TBA from each group presents the outcome of their discussions. This is followed by general discussion, guided by questions and comments of the trainer. The trainer shows the pictures and explains the following points of the role of the TBA, step by step, and allows for comments by the TBAs after each point. 1. Encourage pregnant women to attend ante natal care, including TT 2. Disseminate information on the health center services. 3. Undertake basic health education in the community. 4. Conduct clean normal deliveries. 5. Make timely referrals to government health facilities for women with obstetric danger signs or obstetric emergencies. 6. Report regularly to the health center midwife on the TBA’s deliveries, obstetric complications and related reproductive health problems in the community. 7. Collaborate with health center staff, particularly the midwife, to maintain effective links between community and health center. 8. Support outreach activities of health center staff. 9. Encourage women to start early breastfeeding (before the placenta is delivered) within an hour after delivery. The trainer stresses that the TBA has a very important role to play in her community. She can contribute to better health of the population in her village. She asks: Do you do that ? Do you think that this is what a TBA should do? Would you be able to do this? Why yes or why no? What kind of help would you need? etc) The trainer distributes the handouts to the TBAs. She asks them to mention as many of the activities as possible, from memory. The trainer talks about the ones that have not been mentioned.

Revision

Session 3:
Materials:

Anatomy of the female reproductive tract
Posters of external and internal reproductive organs, handouts, artificial uterus. 45 minutes Explanation, discussion

Lesson time: Training methods: Lesson objectives: Teaching steps Questions

The TBAs know the main organs of the female reproductive tract. They know where the baby develops in a normal pregnancy

Explanation: External reproductive organs

Explanation: internal reproductive organs

The trainer tells the TBAs about the topic and purpose of this session. She asks them whether they know where the baby grows before it is born. Where does it come out? The trainer explains that there are two types of organs: the external ones that one can see and the internal ones which are inside the abdomen and cannot be seen. The trainer shows the TBAs the poster of external reproductive organs. She tells the name of each organ and asks the TBAs what they call them in local words.  The external and interior lips. They are double skin folds that protect the openings of our lower body.  The clitoris. It is a very sensitive spot which makes intercourse enjoyable for the woman.  The urinary opening. The urine is eliminated from here when the bladder is full.  The opening of the vagina. The blood of menstruation comes from here. Every woman should keep this area very clean at all times. This is also the place through which a baby is delivered. The vagina and its opening are very elastic, to accommodate the size of the baby as it is born.  The anus. Feces is eliminated from the body. When a baby is delivered and there is a tear this can sometimes affect the anus. The trainer shows and explains the poster of the internal reproductive organs :  The ovaries. Here one tiny female egg is produced every month. If it is fertilized by male sperm, this starts a pregnancy. If there is no male sperm, menstruation takes place, from the uterus.  The uterus. It is small and hollow (the trainer demonstrates the size, easily fitting into the palm of a hand). During pregnancy the baby grows in it. Then the uterus becomes so big that it fills most of the abdomen.  The cervix. This is the door to the uterus. It is normally tightly shut. In

labour it stretches to open, to allow the baby to get out. It takes several hours of labour till the cervix is fully stretched. Only when it is completely open the mother pushes, so that the baby can be born. The vagina. This is a short channel connecting the uterus to the outside of the body. It can stretch wide. The baby comes through it during the pushing stage of labour.

Revision

The trainer distributes the handouts. She points to each organ and asks the TBAs to describe them. She explains again, if necessary and asks the TBAs to repeat.

Session 4:
Materials:

Normal Pregnancy
Doll with placenta, large flipchart of development of the fetus, picture of anatomy of reproductive tract, newsprint, marker pens and tape. 1.5 hours Explanation, discussion, demonstration, role play

Lesson time Training method: Lesson objectives: Teaching steps:

The TBAs know the signs of pregnancy and development of the fetus. They are able to give advice for minor ailments in pregnancy.

General discussion Explanation: growth of the baby

The trainer tells the TBAs the topic and purpose of this session. She asks the TBAs whether they usually care for a pregnant woman in their village or give her advice? If yes, what do they do and what advice do they give? While showing the pictures of the anatomy of the reproductive tract and the growth of the baby, the trainer explains: After the woman’s egg and the man’s sperm meet it is fertilized and the baby grows in the uterus to become a baby. She asks the TBAs: how many months is the duration of a normal pregnancy? - 9 months or 40 weeks. During the first three months, the baby is still very small. At five months the top of the uterus can be felt near the mother’s umbilicus. One month before delivery it can be felt near the lower end of the rib cage. The placenta develops alongside with the baby in the uterus. The placenta is attached to the wall of the uterus and gets nourishment for the baby from the mother’s blood. The baby and the placenta are connected by the umbilical cord. The baby swims in amniotic fluid in the uterus. The trainer asks the TBAs how the baby lies in the uterus? Encourage them to give their opinion. The baby moves about in the fluid and changes its position many times. But when it comes close to delivery it usually stays in one position: with the head down. The trainer demonstrates this position with the doll and placenta. The baby sometimes, but rarely, also lies in different positions, such as with the head up or sideways. The trainer demonstrates all positions with the doll. Sometimes there are twins and each may lie in different positions. The trainer emphazises:  Any position except the normal one is dangerous to deliver. These mothers should be delivered in a health center or hospital by a trained midwife or doctor. The TBA should tell all pregnant women to go to the health center for ante natal care because the midwife will find out the

baby’s position. We shall talk more about ante natal care in the health center tomorrow. Practice Explanation: signs of pregnancy The trainer gives the doll to TBAs and asks them to show the group the normal position and dangerous positions. The trainer asks the TBAs how a woman usually knows that she is pregnant. She explains the following points, if they have not been already mentioned: Early signs:  Menstruation stops  The woman feels nauseated in the mornings  Heaviness and tingling of the breasts. Later signs:  The abdomen becomes large  The baby is moving The trainer explains that some pregnant women experience problems which are not serious. She asks the TBAs what they could be and writes them on newsprint. If the TBAs mention danger signs (ie serious problems which need referral) please tell the TBAs that we shall talk about those in a separate session tomorrow. She explains the following minor problems and says that the TBAs can give advice on them:  The woman feels sick or vomits in the morning. Advice: eat dry food with no fat, such as rice, bread in the morning. Eat normally for the rest of the day.  Constipation. Advice: Eat more fresh fruit, vegetables, and water  Heartburn (Pain in the upper chest after eating a meal). Advice: Eat less greasy or spicy food.  Swollen feet. Advice: When sitting or lying, raise your feet on cushions.  Muscle cramps in legs. Advice: stretch the muscle slowly by straightening the leg and pointing the toe up. The trainer explains that these problems are not serious and do not need any medicine. They are a normal part of the pregnancy The trainer organizes role plays on minor problems in pregnancy. One TBA plays the mother who chooses one of the above complaints and the other TBA gives advice. This can be repeated with other TBAs and minor problems. The role plays are followed by feed back and discussion by the group. The trainer asks the TBAs whether they give advice to pregnant women about preparations for labour and delivery. If yes, what do they advise? She explains: It is very important that the TBA talks with the woman about the place for her delivery. If the health center midwife has asked her to be delivered at a health facility because of possible complications (a red cross on the white ANC card) the TBA should urge the woman to go to this place for delivery. If no complications are foreseen, the mother could also be delivered at a health

Discussion and explanation: minor problems in pregnancy

Role play

Discussion and explanation: the woman’s preparation for delivery

Revision

center or the TBA could arrange for a trained midwife to attend the delivery in the woman’s home. The TBA will also be there, with the midwife. This is best, in case unexpected complications might occur. If the mother decides on a home delivery she should make the following preparations:  Have a clean place ready for delivery, with a clean mat.  Have a freshly washed sambot ready, as well as several pieces of cloth of different sizes, that are freshly washed and dried in the sun.  There should be a pot with water and fire wood, for boiling.  The woman should take a thorough bath once labour starts and wear a clean sambot. The trainer asks the TBAs to demonstrate the normal and abnormal lie of the baby and asks questions on this lesson.

Session 5: Materials: Lesson time: Training method: Lesson objectives:

Nutrition for the pregnant and breast feeding woman
Nutrition poster, newsprint, tape, marker pens, handouts. 1 hour Explanation with poster, discussion, small group work.

The TBAs know what good nutrition includes and understand its importance for pregnant and breast feeding women.

Teaching steps: General discussion on nutrition The trainer tells the TBAs the topic and purpose of this session. She asks which foods, in the TBA’s opinion, are good for pregnant and breast feeding women. Why are these things good? How much should you eat? Which foods may be bad for these women? Why? Pregnant and breast feeding women need more food than usually because they provide nutrition not only for themselves, but also for their baby. They need not only more food, but also the right kinds of food. That means a variety of foods, besides rice: For instance any kind of meat or fish, eggs, milk, any kind of vegetables and fruit. The woman should also drink plenty; milk is especially good. The trainer explains that many people believe that women should eat different types of food in pregnancy than after delivery. This is not correct. The same foods are good for pregnant women and breast feeding women! The trainer shows the nutrition poster and the TBAs name all the food items shown on it. Discuss whether it is easy to obtain these food items and which ones are expensive, or how you could cook them. The trainer asks which TBAs know about anemia? She explains that this condition is mostly caused by poor nutrition because the body does not get enough iron. If a pregnant woman is anaemic, she may have problems with bleeding after delivery. In order to prevent anaemia the health center midwife gives pregnant women iron tablets at ANC visits. However, iron is present in many foods and the woman should regularly eat those. They include all dark green vegetables, meat and eggs. Divide the TBAs into three groups and give them newsprint and marker pens of several colours. Each group discusses what food they would prepare for a pregnant or breast feeding woman in one day. They draw the dishes and foods on the newsprint. Each group presents their menus to all the TBAs.

Explanation by trainer

Iron-rich food

Develop a healthy menu

Discussion. Explanation : Insufficient food The trainer explains the importance of good nutrition in pregnancy and while breast feeding. If a woman does not eat enough or she does not eat the right foods, her labour may be prolonged, she may bleed too much after delivery or she may become weak or ill quickly. Her baby could be small and weak. The trainer explains that our food and drink passes into the unborn baby through the placenta and into breast milk. Therefore, alcohol and smoking should be avoided because it can harm mother and baby. Medicines should only be taken if they are advised by a doctor who knows that the woman is pregnant or breast feeding because some medicines can affect the baby badly. The trainer distributes the nutrition handout to the TBAs and gives them time to look at the picture. She uses this picture to revise the main food groups and the importance for good nutrition. She stresses that the TBA should give good advice on healthy nutrition to all women in her community who are pregnant or breast feeding.

Explanation: what to avoid

Handouts/ Revision

Session 6:
Materials Visit time Training method Objectives: None 1.5 hours

Health center visit

Visit each room of the health center, explanation, discussion

The TBAs know the health center staff and have basic knowledge of their work. They are aware of opening hours and referral procedure.

Preparations

The trainer chooses a suitable health center, preferably where a LSS-trained midwife works. She plans the visit with the health center chief, ensuring that on the appointed day all health center staff are present and that they are ready to guide the TBAs through the health center. Staff should describe their work briefly to the TBAs. The trainer discusses with the health center chief how the TBAs could be made welcome and comfortable. At the end of their visit the TBAs should have the impression that they are valued as link persons between their community and the health center. If the visit takes place in another village than the one where the TBA training takes place, transport has to be arranged. Health center staff guide the TBAs through all rooms and describe the work which is being done there. They reply to questions of TBAs. The trainer asks questions on subjects which are useful, if they are not already mentioned, such as: do deliveries take place in the health center? When is the health center opened? How exactly are referrals conducted, step by step? What is the procedure if an emergency patient is being referred when the health center is closed? What does a patient have to pay? What can the TBA do? Once the group has returned to the training room, the trainer asks them about their impressions. She emphasizes the main points learnt. She discusses with the TBAs how they could best interact with health center staff.

The visit

Feedback

Session 7:

The five Cleans
Poster of “five cleans” , plastic bowl, bucket with water, nail clippers, soap in soap dish, plastic sheet, 3 cord ties, 2 glasses with water, some salt, spoon, handouts 2 hours Explanation, discussion, demonstration, practice

Materials:

Lesson time: Training methods: Lesson objectives:

The TBAs understand how microbes cause illness The TBAs know the five clean actions for clean deliveries The TBAs are able to perform clean delivery techniques.

Teaching steps Discussion on illness

Explanation and demonstration: microbes

Explanation: how microbes are transferred

Explanation: How to kill microbes

The trainer tells the TBAs about the topic and purpose of this session. She asks the TBAs about persons in their family who have become ill. How do they think this illness was caused? How was this person treated? What was the outcome? The trainer should show an interest in their traditional treatments and not blame them if they seem to have acted wrongly. The trainer explains that illness is transmitted by microbes. These are very tiny worms that one cannot see. If they get into the body they cause illness. The trainer fills two glasses with water. She puts a small amount of salt into one glass and stirs till it is dissolved. She explains that the water in both glasses looks the same, but one has salt in it. One cannot see the salt, but it is there. It is the same with the microbes: they are there, but we cannot see them. The trainer explains that microbes can be found everywhere, on every surface, on clothes, in fluids, food, feces and in the air. Anything that is not clean has millions of microbes. These microbes can be transferred in many ways, for instance by touch (from something dirty to something clean), by flies (they land first on something dirty and then on something clean), by fluids (from dirty water onto the body or a clean surface), by food (by eating something dirty). Microbes can get into the body easily through wounds. That is the reason why we must be so careful about stopping them to get into the mother via the vagina (it may have tears) and into the baby’s umbilical cord. The trainer asks: How can we kill microbes? The answers should include:  By boiling: if we boil water this kills all microbes. If we boil something in water, for instance the cord ties for a baby’s umbilicus, this kills all the

Explanation: the five cleans

Practice role play

microbes on the cord tape.  By washing with soap. If we wash our hands, body, clothes or surfaces thoroughly with soap, this kills the microbes.  By some special solutions, for instance Gentian Violet. If we put Gentian Violet on to the baby’s cord stump, it will kill the microbes.  By the sun. Some microbes get killed if we put clothes into strong sunlight. But it has to be for a long time and it will not kill all the microbes; so the first three methods are better. The trainer explains: it is very important that we perform clean deliveries for women, in order to prevent illness for them and the new-born baby. We can do this by killing the microbes, so that we have five types of very clean things:  Clean hands of the TBA  Clean scissors or razor for cord cutting and then boil it  Clean cord tapes  Clean surface for the mother to lie on  Clean vulva of the mother. How can we achieve this? :  Wash hands carefully with soap  Boil cord tapes and scissors or razor blade in water for at least 20 minutes after the water starts boiling. The trainer discusses with the TBAs how long 20 minutes is. ( as long as it takes to burn one incense stick or as long as it takes to boil rice)  Thoroughly wash a large cloth or plastic sheet, to put under the mother, and dry in the sun.  Wash her vulva with soap and boiled water, from front to back. The trainer shows and explains the poster of the 5 clean. Then she demonstrates hand washing: She first removes her rings, then uses nail clippers. She washes hands and arms, up to the elbow, very carefully. She holds hands and lower arms up till they are dry. She explains that the TBA should do this every time a mother in labour comes near delivery. Several TBAs practice hand washing in front of the group. The group makes comments. The trainer reinforces the hand washing steps and repeats their importance. The trainer asks questions on all above points. She fills memory gaps where necessary and encourages further discussion. She distributes the handouts and gives the TBAs time to look at the pictures. She asks the TBAs to describe the pictures. Further discussion if enough time.

Revision

Session 8:

Routine ante natal referrals and danger signs in pregnancy
Poster of ante natal care, picture cards of danger signs, handouts 2.5 hours discussion, demonstration with pictures, game

Materials: Lesson time:

Training methods:

Lesson Objectives: The participants understand the reasons why every pregnant woman needs ante natal care from a midwife. The participants recognize the danger signs in pregnancy and refer these women soon. Teaching steps: Tell the participants about the two topics and purpose of this session.
First we will talk about ante natal care.

General discussion ANC Discuss poster

Explain ANC

Explain importance of ANC

The trainer asks which TBAs have sent pregnant women to the health center for ANC? Why did they send them? Do the women want to go? If yes, why? If no, why? Do you think it is good for a pregnant woman to go to the HC for ANC? Why or why not? Does a mobile team from the health center come to your village? Ask what do you think the midwife does at ANC? The trainer shows the poster of ANC at a health center. She asks: what do you see on this poster? She explains that one of the services of a health center is to provide ante natal care. At an ANC session the midwife:  Checks the woman’s abdomen, to feel how the baby lies.  Listens to the baby’s heart beat  Takes the mother’s blood pressure  Checks for anaemia and gives iron tablets  Ensures that the mother is in good general health  Gives advice how to stay healthy in pregnancy.  If she finds problems, she takes the correct action.  She sends the woman for TT vaccination. The trainer emphasizes why ANC is so important: To make sure that the pregnancy is normal, so that mother and baby are in good health. If there are problems, the midwife will find them and give care.
The TBA should send ALL pregnant women for Ante Natal Care to the Health Center or to outreach sessions by mobile health center teams.

Each woman should attend at least twice during each pregnancy. The women can decide on a convenient time to go, but in the 4th month is

General discussion on TBAs’ experience with danger signs

Pictures of danger signs and stories on each picture.

best for the first visit. To reinforce the message the trainer repeats with questions like: Who should go to ANC at the health center? Why? How many times? When? The trainer introduces the next topic: Danger Signs in Pregnancy She asks whether any TBAs have noticed any signs of danger in the pregnancy of women. What was it? What was the outcome of these pregnancies? What did the TBAs do? The trainer explains that many women die in pregnancy, labor and after delivery. TBAs can prevent deaths of women and babies by looking for danger signs and referring women very quickly. The trainer shows the pictures of danger signs one after each other. She makes up a name for each woman on each picture and tells a little story about her having this condition. She should stress the following danger sings:  Fever can be caused by many different illnesses and the woman needs medicine from the health center. The fever can harm her unborn baby.  Bleeding from the vagina she must be referred very quickly, especially if the bleeding occurs after the baby has started moving.  Swelling of hands and face  Severe headache and blurred vision the woman may lead to convulsion and die.  Premature rupture of membrane Note: If the baby is in malpresentation in the uterus, this causes severe problems during labour and delivery and the woman should be referred.

Revision game

Emphasize urgency of referral Revision

Divide the TBAs into five groups. Put all danger cards on the floor or table upside down, so that no one can see the picture. Let each group take one card. Ask them to discuss this card in their group. Each group makes up a story about a woman with the danger sign on this card. One person in each group tells the story to the whole group of TBAs. The trainer comments and asks questions about the women in the stories; for instance: I think Mrs X does not want to go to the health center. How do you persuade her? Mrs Y does not think that swelling of hands and face is dangerous. How do you answer? Mrs Z does not like the HC midwife. What do you do or say to help her? The trainer emphasizes that it is very important for a woman with danger signs to go to the health center very quickly. For ANC the woman can go whenever it is convenient, but if there is a danger sign, we cannot delay! The trainer distributes the handouts on danger signs. She asks the TBAs to look at each picture and identify the danger signs one by one.

Session 9:
Materials:

Normal labour
Doll, placenta, pelvis, role play clothes, handouts, saucepan with water, plastic sheet, several pieces of cloth of different sizes, picture of “what NOT to do” and picture of normal delivery, 3 pillows or bolsters. 2 hours Explanation with posters, discussion, demonstration, role plays. The TBAs are able to give appropriate care in labour.

Lesson time: Training method: Lesson objectives: Teaching steps General discussion on TBA’s labour and delivery practices Explanation: true labour

The trainer tells the TBAs the topic and purpose of this session. She generates a discussion on TBAs' labour and delivery practices, when they conduct a home delivery, their actions as soon as the baby is born, interaction with family, problems and how they are solved.
The trainer asks: when does true labour start? She explains that true labour is established with regular, painful contractions. We can feel contractions by placing our hand on the woman’s abdomen. With each contraction the abdomen becomes hard, like wood.

Explanation: care in early labour

Explanation: pushing time and delivery

The TBA should ask the family to call her as soon as the woman has regular, painful contractions. The trainer asks the TBAs how they assist a woman in early labour (before she wants to push). She tells the TBAs that during this session we will act as if we do NOT have the RACHA home-birth kits. She advises the following actions:  The TBA establishes that the mother is in true labour.  She asks the woman to pass urine and stool.  She asks the woman to take a thorough bath.  She encourages the woman to walk  She starts boiling cord tape and scissors for 20 minutes.  She checks that clean cloths and boiled water are ready and nearby.  She encourages the woman to take soft food and drink She massages the woman’s back and shoulders (NOT the abdomen!) The trainer explains that the TBA’s should do the following for the pushing time:  She washes her hands carefully. When she can see the mother's perinuem bulging/a small bit of the baby’s head at the vulva she puts on her clean gloves.  The woman should only begin to push if she strongly feels like pushing.

Role play

Demonstration

She should only push when she has the pain and rest in between pains.  For the pushing phase the woman can choose the most comfortable position for herself: sitting, sitting on a bucket or bowl, squatting, going on hands and knees, or lying down, with upper back and shoulders supported by cushions, so that she is in a half-sitting position. A relative can support her in the half-sitting position.  Put a clean plastic sheet or large clean cloth under the woman.  Wash the birth opening (vulva) from front to back with soap and boiled water.  Once the head is born, feel around the neck for the umbilical cord. If it is around the neck, try to loop it gently over the baby’s head. The trainer demonstrates this with the doll.  Wipe baby's eyes and mouth with small clean cloths, which have been prepared. Wipe its whole body and dry with a larger clean cloth.  Tie and cut the umbilical cord, wrap the baby with another clean cloth (we will learn how to cut and tie the umbilical cord next session).  Straight away put the baby on the mother’s stomach and let it suck on her breast. This is very good for the baby and also makes the mother’s uterus contract, so that the placenta comes out quickly and the mother’s blood loss is reduced. The trainer asks two TBAs to perform a role play of care of mother during labour, the pushing time and delivery. After the role play all TBAs give comments and discuss. The TBAs practice looping the cord across the baby’s face, if it is around the neck. The trainer shows the picture of how the baby moves through the birth canal. and is born, and demonstrates how to care for mother during labour, the pushing time, and delivery by using doll and pelvis. The trainer explains the following harmful practices and stresses that the TBA should NEVER do them because they can make labour and delivery go wrong:  Never give injections or other medicine  Never put your fingers into the vagina  Never push on the mother’s abdomen The trainer shows the picture of these actions and points to each forbidden intervention, asking individual TBAs what they are. She emphasizes again that these should never be done. The trainer distributes the handouts amongst the TBAs and gives them time to look at the pictures. She asks again what the pictures represent and explains again, if necessary.

Explanation: harmful practices

Handouts

Session 10:

Placenta delivery and immediate care
36 pieces of cord tape, 6 pieces of soft cord, plastic bowl, plastic bag, gauze, baby cloths, placenta and cord, 3 pairs of scissors, Gentian violet, milk can and water. 1.5 hours Explanation, demonstration, practice. The TBAs are able to deliver the placenta and give appropriate care for mother and baby soon after delivery.

Materials

Lesson time Training method: Lesson objectives: Teaching steps: General discussion

Cord cutting demonstration

Practice of cord cutting

Explanation and demonstration: delivery of

The trainer tells the TBAs the topic and purpose of this session. She asks the TBAs about how do they care for the mother and baby? How do they cut the cord? How do they treat the cord? How do they deliver the placenta? What do they do with the placenta? What problems do they encounter and how do they solve them? How long do they stay with the mother after the birth? The trainer explains that it is most important that the cord is cut with a very clean instrument on a very clean surface. Otherwise the baby is at risk of getting an infection or Tetanus. The trainer demonstrates with a prepared piece of cord and three tapes how the cord has to be tied three times : the first knot at a distance of two fingers width from the umbilicus, the second one further finger width from the first tie and the third at two fingers width from the second tie. Make the ties firm, so that no blood can trickle through when cut. Then cut the cord with the clean scissors or a new blade between the second and third knot. Apply Gentian violet, if available to the cord stump. Do not apply anything else! The trainer divides the TBAs into groups of two persons. She gives each group one cord and 6 ties. One TBA in each group ties the cord. The trainer checks this. These TBAs cut the cord (scissors will have to be shared). The trainer checks this. Then the other TBA in each group takes her turn in tying and cutting the cord. The trainer explains that the placenta normally comes out within an hour of the birth of the baby. If the mother lets the baby suck on her breast straight after delivery, the placenta will come out sooner.
The trainer asks the TBAs whether they know when the placenta is ready to come out. The answers should include the

placenta

following:

 A small gush of blood comes from the vagina.  More of the cord can be seen on the outside of the vulva. The TBA should guide the placenta out slowly, by the cord, but never pull on the cord. The TBA should examine it carefully, to make sure that it is complete and no piece is left behind in the woman’s uterus. If a piece of the placenta is missing, the woman has to be referred to the health center.
After the placenta is checked, it should be placed into a plastic bag and given to the family for disposal

Explanation and demonstration: blood loss Explanation: care of the mother

Revision

The trainer demonstrates this process with the cloth placenta, the pelvis (which is partially covered with a sampot) and the plastic bowl. After that she asks a few TBAs to do the same demonstration. Discussion. The trainer explains that normally the woman loses approximately as much blood as would fit in one milk can. This is normal. The trainer takes one can of water and spills them it on a large piece of cloth. If the blood loss is more than this, it is a danger sign. We shall talk about this in one of the next lessons. Once the placenta is delivered the TBA should care for the woman in the following way:  Rub the abdomen till the uterus is firm, like a small ball.  Show the woman how to feel for her own uterus and how to rub it  Check the woman’s blood loss per vagina very often. The bleeding should not be more than for a normal menstruation.  Ask her to pass urine.  Make the woman comfortable and offer her food and drink  Let the baby breast feed often The trainer asks questions on immediate care of the mother, baby, cord tying, delivery of placenta and blood loss. Clarify any points which are not fully understood or well remembered. Emphasize again what NOT to do:  Do not put anything on the baby’s cord, except Gentian Violet!  Do not pull on the umbilical cord, while delivering the placenta!

Session 11
Materials: Lesson time: Training methods: Lesson Objective: Teaching steps:

Danger signs during labour and delivery
Pictures of danger signs during labour and delivery, handouts. 2 hours Discussion, demonstration with pictures, game.

The participants recognize the danger signs during labour and delivery and refer these women as soon as possible.

General discussion

Pictures of danger signs and stories on each picture.

Discuss action

Revision game

The trainer tells the TBA about the topic and purpose of this session. She asks the TBAs whether they have encountered situations during labour and delivery which have posed problems? If yes, what were they? Encourage general discussion on these situations. What did the TBA do? What was the outcome of these labours for the mother and baby? Did anyone beside the TBA help? The trainer explains that many women die during labour and delivery. The TBA can prevent these deaths by looking for danger signs and by referring these women immediately. The trainer shows the pictures on danger signs in labour or delivery one by one. She makes up a name for each woman on each picture and tells a story about her having this condition. The trainer should stress the following points:  Heavy bleeding from the vagina. This is very dangerous and can lead to sudden death.  A hand, foot or the baby’s cord appears in the vagina during labour. The baby is in the wrong position. If the cord comes out first, the baby’s blood supply is cut off. All these situations are very dangerous for mother and baby.  Convulsion. The life of mother and baby are in serious danger.  Green amniotic fluid. This means that the baby inside the uterus is in distress.  Labour which is too long, taking one day and night or more. Or pushing that takes longer than two hours for first pregnancies or longer than one hour for women who have had more than one pregnancy. The trainer shows each picture again, one by one. She asks for each picture how a TBA can find out whether a woman in labour has this condition? What can the TBA do? – refer very quickly! Where ? Discuss. Divide TBAs into five groups. Put all danger cards for labour or delivery on the

Emphasize urgency of referral Handouts

table or floor, upside down, so that no one can see the pictures. Let each group take one card. Ask them to discuss this card in their group. Each group invents a story about a woman with the danger sign on this card. One person of each group tells their story to the whole group of TBAs. The trainer comments and asks questions about the women in these stories and their families, to highlight problems of referral. General discussion. The trainer emphasizes that it is very important for a woman with danger signs to get to the health facility as quickly as possible. The community should help. The trainer gives the session’s handout to the TBAs and allows time for them to look at the pictures. Ask the TBAs to identify each danger sign, how it can be recognized and what action should be taken?

Lesson 12:
Materials : Lesson time: Training method: Lesson objectives Teaching steps: General discussion on danger signs for mothers

Danger signs after delivery
Pictures of danger signs for mother after delivery, baby doll, cloth for baby, handouts. 2.5 hours Discussion, demonstration with pictures, game, role play. The TBAs recognize the danger signs after delivery in the woman and her baby and make appropriate referrals.

The trainer tells the TBAs about the topic and purpose of this session. First we talk about danger signs in a woman after the delivery of her baby. The trainer asks the TBAs what health problems women sometimes have after they have delivered their baby. Discuss each condition which is mentioned by the TBAs. What do they do to help? The trainer then explains that some problems are very serious and that the TBA can help by timely referrals. The trainer shows the pictures on danger signs for woman after delivery, one by one. She makes up a name for each woman on each picture and tells a story about her having this condition. However, she does not talk in detail about the post partum hemorrhage and tells the TBAs that this will be the subject of a separate session. The trainer should stress the following points:  The placenta does not come out of the uterus for more than one hour after delivery. This is especially dangerous because it can cause severe bleeding.  Bright red vaginal bleeding. This is a very dangerous problem and we shall talk about it in a separate session because there are several things that the TBA can do.  Fever, with bad smelling discharge from the vagina. This indicates an infection of the uterus which can cause death or make the woman infertile.  The uterus is not contracted/descent (it should be firm like a small ball). The cause may be that some of the placenta is retained in the uterus. It can cause severe bleeding.  The woman’s breast is red, feels hot and is painful. These are the symptoms for an infection of the breast. The mother needs medicine from the health center. She should continue breast-feeding. The trainer asks how the TBAs can detect these danger signs. What is

Pictures of danger signs for women and stories on each picture.

Discuss action

their action? Prompt referral. The trainer divides the TBAs into five groups. She puts all danger cards for Revision game women after delivery on the table or floor, upside down, so that the pictures cannot be seen. Each group takes one card. Each group discusses the danger sign on the card amongst themselves. They invent a story about a woman with this condition. One TBA of each group tells the story to all the TBAs. The trainer asks questions about the women in these stories and their families and encourages general discussion on the presented cases. The trainer again emphasizes the urgent need for referrals. General The trainer tells the TBAs that now we shall talk about danger signs in discussion on newborn babies. She asks what health problems babies sometimes get after danger signs for birth. Discuss each condition mentioned by the TBAs. What can they do to new-born babies help? The trainer describes the following danger signs in newborn babies: Specific danger  The baby is not breathing normally. It means that there is a serious signs problem.  The baby’s cord is red or covered with pus. This means that the cord is infected and the baby is very sick. It needs medicine from the health center.  Fever indicates sickness and the child needs medicine from the health center.  Baby is not sucking, or not sucking well. This may mean that the baby is too weak or sick. The mother should express her milk into a clean cup and give it with a clean spoon. If the baby has tetanus it will also not be able to suck.  The baby has red, swollen eyes with pus. If this condition is not treated with medicine from a health center quickly the baby may go blind. The trainer emphasizes that all babies with these danger signs need to be referred. With the doll the trainer shows the TBAs how to examine a baby from head Role play to toe, to look for danger signs. She divides the TBAs into five groups and each group chooses one danger sign for their role play. One TBA plays the mother, another of the same group plays the TBA. The TBA asks the mother about her baby’s condition. Then she does the head to toe examination on the doll and advises the right action. All five groups perform these short roll plays in front of all the other TBAs. After each role play the trainer and TBAs ask questions and discuss. The trainer distributes the handout picture on danger signs for women and allows time for them to look at the pictures. The trainer asks the TBAs to identify each danger sign on the picture. Then she revises the danger signs for newborn babies. She again emphasizes the need for prompt referral in all cases.

Handouts

Lesson 13:
Materials:

Post Partum Hemorrhage
Role play clothes, cloth placenta, poster of actions for post partum hemorrhage, handouts, small round cushion, small ball. 1.5 hours Explanation, demonstration, role plays, discussions. The TBAs are able to perform the correct actions in case of retained placenta or post partum hemorrhage.

Lesson time: Training method: Lesson Objectives:

Teaching steps: General discussion The trainer tells the TBAs the topic and purpose of this session. She asks the TBAs whether they have cared for women who have retained their placenta too long or had too much bleeding after delivery. How was it? What did the woman feel like? What did the TBAs do? Was anyone else involved in the care? What was the outcome? She explains that many women die of this condition and that the TBA can sometimes save their life by taking the right action quickly. Excessive bleeding after delivery is one of the most serious problems which can happen to a woman and it is very important that the TBA acts very fast in referring her. The trainer revises: How much time passes usually after delivery of the baby, for the placenta to come out? It should normally come out within one hour, but usually it is shorter than that, especially if the baby sucks at the breast. If the placenta has not come out for half an hour the TBA can do the following:  Get the baby to suck at the breast.  Ask the mother to squat down and push  Ask the mother to cough, sneeze or vomit.  Ask the mother to pass urine, even if she does not feel like it.
When the placenta is delivered the TBA must not forget to examine it for completeness. She must feel the abdomen very often to check that the uterus is hard like small ball. If not, she should massage the abdomen. She also should observe the vulva for excessive bleeding. She should stay with the woman for several hours and keep observing her.

Explanation: Retained placenta

If all these actions to help deliver the placenta have no effect and the placenta is still retained, the TBA should call a trained midwife or make preparations to transfer the woman to the health center.
Note: If the placenta has not come out and the woman has severe bleeding, refer as soon as possible.

Role play

The trainer performs a role play and then asks two TBAs to perform a role play of a woman whose placenta is not coming out. After this the TBAs discuss the play. The trainer fills in gaps and makes clarifications if necessary. The role

play can be repeated by two other TBAs. Explanation and demonstration of hemorrhage after delivery of placenta. After the placenta is delivered, the woman sometimes loses more blood from the uterus than normal and this is very dangerous. The trainer shows the picture and explains that the TBA should do the following things to stop the bleeding:  Let the baby suck at the breast  Ask the woman to pass urine.  Lay the woman flat and raise her feet on pillows.  Give her something to drink, if she can drink.  Massage the uterus till it feels hard like a small ball. The trainer puts the small ball under a sampot above her skirt or trousers and lets the TBAs feel this. If the uterus feels big and soft and it will not change into a small ball shape after all the above actions, the TBA should perform the following:  She holds one hand on the abdomen against the highest ridge of the soft uterus, near the umbilicus.  She puts her other hand along the lowest ridge of the uterus, on the abdomen, near the pubis.  She presses the uterus together with both hands, on the abdomen. She holds her hands like this for at least ten minutes. This sometimes helps to stop the bleeding. The trainer demonstrates this action with the small round cushion that is under a sampot. The TBAs practice this one by one. The trainer explains: if all the actions we have talked about do not stop the bleeding quickly, the TBA must call a trained midwife or refer the woman as fast as possible to the nearest health facility. Every minute is precious in these cases! Note: During compression, If the bleeding is still continuing, refer immediately Two TBAs perform a role play about a woman with excessive bleeding after delivery, after the placenta is delivered. All actions should be demonstrated in the role play. After the role play the TBAs discuss it and the teacher fills in any gaps or clarifies misunderstandings. She again emphasizes the urgent need for prompt actions to save these women’s lives. The trainer distributes the handout and asks the TBAs to explain each action on the picture. She asks questions on all subjects of the session.

Role play

Revision

Session 14:
Materials

Post Natal Care
Picture of woman going to health center, baby doll, cloth for baby, gentian violet, small ball, handout. 1.5 hours Explanation, discussion, role plays The TBAs understand a woman’s physical changes in the post natal time and are able to provide appropriate care for the woman and baby.

Lesson time Training method Lesson objectives

Teaching steps Group discussion The trainer tells the TBA the topic and purpose of the session. She asks what the TBAs usually do after a woman has delivered her baby. How long do they stay with the woman? Do they go back to visit her? If yes, how many times approximately? What do they do or advise? The trainer explains that it takes approximately 6-8 weeks till a woman’s body returns fully to normal, after the baby is born.  The uterus can be felt near the umbilicus on the first day. Then it moves down in the abdomen by approximately one finger’s width every day, till it cannot be felt anymore after 12 days.  The normal discharge (lochia) from the vagina is blood for about the first four days, like a normal menstruation. Then it becomes pink for another five days and white for a further five days till it disappears completely. If blood continues to come after the first four or five days, this may mean that a small piece of the placenta is still inside the uterus. The woman should be referred to the health center then. Whenever the TBA visits a woman in the first 12 days after delivery, she should:  Feel the uterus through the woman’s abdomen  Look for discharge from the vagina The trainer revises briefly the main points of good nutrition. The TBA gives the following advice:  It is very important for the woman to eat nutritious meals, to regain her own strength and have plenty of milk for her baby.  It is also important that she keeps herself very clean, to avoid microbes

Explanation of physical changes in the mother and care

Explanation: advice

Role play

Explanation: care for the baby

Role play

Revision

making her sick.  The mother should feed her baby with breast milk only ( we shall talk about breast feeding in the next lesson) The woman should visit the health center with her baby approximately six week after the birth, for a health check up. She should then also get the first vaccinations for her baby. She may wish to talk with the midwife about birth spacing. The habit of “roasting” should be discouraged because it can be harmful to the mother and baby. Discussion on the dangers of roasting. Two TBAs perform a role play of a home visit to a woman who has delivered a baby three days ago. This should include an examination of the woman and baby, as well as advice. After the role play the TBAs give their feed back and the trainer fills in gaps and clarifies misunderstandings. Then two different TBAs perform another role play of this kind, of a home visit to a woman who has delivered her baby seven days ago and says that bright red blood is still coming from her vagina. The uterus can be felt high in the abdomen. When the TBA visits the mother at home she should also care for the baby. Does it look normal?  She should observe the mother breast feeding and give advice if necessary (we shall talk about this more in the next session)  She should look at the baby’s umbilicus which should be clean and dry. If possible she or the mother should put Gentian Violet on the cord stump every day, to kill microbes. Nothing else should be put on the cord! If the TBA sees pus on the stump or she notices a bad smell coming from it, she should refer the baby to the health center for medicine because the baby could be very ill. The trainer demonstrates with the doll and gentian violet, how the cord should be cared for. Two TBAs then perform a role play of caring for the baby at a home visit. This should include breast feeding and cord care. Discussion follows and the trainer fills gaps of knowledge and clarifies misunderstandings, as necessary. The trainer distributes handouts and asks questions on every section of this lesson.

Session 15:
Materials Lesson time: Training method: Lesson objective Teaching steps General discussion Revision of danger signs

How to refer a patient
Pictures of danger signs in pregnancy, labour and after delivery. 1 hour Explanation, discussion, role play The TBAs are able to make timely and appropriate referrals

Explanation on step by step referral actions

The trainer tells the TBAs the topic and purpose of this session. She generates a discussion on the TBAs’ experience with referrals. How do they organize referrals? What are the problems and how do they solve them? What could they do if a woman refuses to be referred? The trainer revises the danger signs in pregnancy, labour and after delivery while showing the relevant pictures. She must ensure that all TBAs know these very well. The trainer explains the steps which have to be done for good referrals:  Always maintain good relationship with the health center midwives. Know the opening hours of the health center. Know the homes of health center midwives. Discuss what action should be taken if someone needs to be referred at night time. Does the health center have transport? Can transport be requested from OD hospital? What problems might arise?  Prepare a possible referral in your village, even before a referral becomes necessary. Keep good relationship with the Village Chief or Feedback Committee members. Who could help in the village in an emergency? What transport can be mobilized?  When a woman has to be referred, involve the family and friends, such as preparing clothes, money, food, help with other children etc.  If the mother is referred after the birth, ALWAYS take the baby with her!  If possible the TBA should accompany the woman to the health center or hospital. On arrival, please tell the midwife all you know about this woman’s condition  Once the woman has returned from the health center or hospital, please visit her. She may need your support and advice. The trainer arranges the following role play: Ms Sokha has been in labour all day and night. It is her third pregnancy. The TBA notices that the baby’s hand and arm have come out of the vagina. What will the TBA do? If there is time another role play can be done on another danger sign, perhaps bleeding per vagina in a woman five months pregnant. Discussion after each role play. The trainer asks the TBAs questions on all points relating to referrals.

Role play

Revision

Session 16:
Materials: Lesson time: Training method: Lesson objectives 0.5 hour

Breast feeding

Breast feeding poster, handouts.

Explanation, discussion. The TBAs know the advantages on breast feeding and are able to give advice on early and exclusive breast feeding.

Teaching steps General discussion The trainer tells the TBAs the topic and purpose of this session. She asks why the TBAs think that breast feeding is good? Discussion. When do they think the mother should begin to breast feed? Should the mother give the baby other food or drink besides breast milk? How long is a baby breast fed usually? The trainer shows the breast feeding poster and explains those advantages of breast feeding which the TBAs have not mentioned in the above discussion. They should be  Breast milk is the perfect nutrition for the baby  It is always clean  It costs no money  Makes the mother’s uterus contract and reduces bleeding  Protects the baby from infection, especially colostrum  Can prevent pregnancy. (We shall talk about this in the next session more. ) The trainer explains that the baby should be put to the breast as soon as it is born; even before the placenta is delivered. Certainly during the first hour after the birth.  The very first, thick and creamy milk (colostrum) is very good for the baby. It contains just the right nourishment. It also protects the baby from infection. The TBA should advise the mother to let the baby suck very often. Nothing else should be given to the baby! The trainer explains that the TBA should advise the mother:  She should give breast milk only for the first six months. No other food or drink is needed!  After six months the baby needs other foods, beside breast milk, but breast feeding should continue for the baby’s first two years.  The mother should let the baby suck often. The more the baby sucks, the more milk will be produced by the mother’s body.  She should let the baby finish all the milk in one breast before giving the

Explanation: Advantages of breast feeding

Explanation: Early breast feeding.

Explanation: Exclusive breast feeding

Revision

other breast.  The mother should eat good nourishing food (as we have discussed in an earlier session) and take plenty to drink. The trainer distributes the breast feeding handouts. She asks questions about breast feeding, emphasizing the main points: early breast feeding, the value of colostrum, exclusive breast feeding for six months.

Session 17:

Family Planning

Materials

samples of contraceptive pill, condoms, Depo Provera, artificial penis or banana 0.5 hours Explanation, discussion, practice.

Lesson Time: Training method: Lesson objective:

The TBAs are able to make appropriate referrals for family planning.

Teaching steps Definition and discussion The trainer tells the TBAs the topic and purpose of this session. She asks the TBAs what family planning is. The answer should be:  A method to prevent pregnancy after intercourse. Like this every couple can choose how many children they want and when they want another pregnancy. The trainer asks the TBAs whether they think that FP is good or not. Why? Discussion on this topic. The trainer explains that rice which is not planted too closely, grows better. With children it is similar: If there is a gap of two years or more between pregnancies, the children will be stronger. The trainer explains the advantages of family planning if they have not already been mentioned by the TBAs:  If there is a gap between pregnancies of two or more years, the mother will be healthier because she will regain her strength.  If there is a gap between pregnancies of more than two years, the baby will be healthier because it can breast feed longer.  If a family does not have too many children too quickly the family can care for their children better.  If a poor woman is not pregnant all the time she can help to work to increase the family’s income and they will be less poor. The trainer asks whether the TBAs know of any methods of family planning. If yes, which ones? The trainer explains that there are many methods, but now we shall talk only about the ones which the health center midwife offers (The trainer shows each sample)  The pill. Here the woman takes one pill every day to stop her from

Explanation: advantages of family planning

Explanation and practice: some methods

 

becoming pregnant. Each card has enough pills for one month. The health center midwife provides them. The injection. The woman gets one injection from the health center every three months. This stops her from becoming pregnant. The condom. The man puts it over his penis when having intercourse. The trainer passes condoms around and demonstrates how to put them on, on a banana or artificial penis. The man uses one new condom at each intercourse. They are cheap and can be bought at the health center and other shops. The breast feeding method: If the mother breast feeds she will not become pregnant for the first six months after the baby is born and before the menstruation restart. However, she has to breast feed exclusively and many times a day and night, so that this method works well. It costs nothing and the baby gets the best food.

Revision role play

If there is enough time, family planning advice on advantages can be practiced in role plays. It is most important that the TBAs know to refer a woman who might be interested in family planning.

Session 18:
Materials Visit time Training method Objectives

Referral Hospital visit
None 2.5 hours Visit to Referral Hospital, tour through hospital, explanation, discussion The TBAs have basic knowledge of the hospital’s departments and activities, especially the maternity unit. The hospital’s maternity midwives and doctors recognize the role of TBAs in obstetric referrals from villages. The trainer visits the Referral Hospital several days before the planned TBA visit, to meet the hospital director. She asks him for permission for such a visit and explains its objectives. (see above). She requests that the TBAs should be permitted to see all sections of the hospital (not only the maternity). The trainer discusses with the hospital director how this visit can become a positive experience for the TBAs because they sometimes are afraid to accompany referred patients to the hospital, for fear of being blamed. After meeting the hospital chief the trainer meets the maternity chief and maternity staff, to prepare the TBA visit. She explains that TBAs play an important role in referrals of patients from their villages. Therefore it is important that they feel well accepted in the hospital and that they do not need to fear that they may be blamed when referring patients. Transport will have to be arranged. The TBAs and trainer are being guided through the hospital. Health staffs inform them of the activities and reply to questions. At the maternity unit the group spends more time and talks with the midwives in more detail. The trainer guides the discussion and ensures that relevant subjects are being addressed, such as: Does the hospital have an ambulance service? Can the ambulance be called from any health center? If a patient is referred from a health center, should the TBA come with the patient? What kind of information does hospital staff need when a patient is referred? Can referred patients be received at the hospital at any time? After the visit is finished, the TBAs have a meeting with the RH director. Once the group has returned to the training room the trainer generates a discussion on the visit and obtains the TBAs’ honest opinion. What have they learnt from this experience? In which way may it help them with referrals in the future? What were the positive points of the visit and what were the negative points? The trainer tells the TBAs the objectives of this visit (see above) and asks them whether they think that these have been achieved. Did they get the impression that the hospital midwives appreciate the collaboration with TBAs?

Preparation

The visit

Feed back

Session 19:
Materials: Lesson time: Training methods: Lesson objectives: Teaching steps General discussion

HIV/AIDS

Poster on HIV/AIDS transmission, handouts and card game 1 hour Discussion, explanation, game.

The TBAs know the main methods of transmission of HIV and prevention of HIV infection.

Explanation: symptoms

Explanations: ways of transmission

The trainer tells the TBAs the topic and purpose of this session. She asks whether any TBAs have heard of the disease AIDS? If yes, what have they heard? Does anyone they know have AIDS? Can it be cured? If yes, how? Can it be prevented, if yes, how? The trainer explains that this illness exists all over the world. There is no cure for it. Some medicines make the person become better for a while, but they are extremely expensive and one cannot get them in Cambodia. Local medicine does certainly not cure it. The patient or person living with HIV becomes ill with many symptoms very often, such as sometimes with skin rashes, sometimes coughs, sometimes diarrhea or fever. The person becomes very thin and weak and finally dies. The trainer explains that AIDS is caused by a microbe which is called HIV. Once this microbe is in the body it may not make the person feel sick for a long time, sometimes several years. Then the illness AIDS begins. The trainer shows the poster of HIV transmission and explains the main ways in which HIV is transmitted:  Most often the HIV microbe is transmitted by sexual intercourse when one partner has HIV already.  The HIV microbe can be transmitted from the blood of a person infected by HIV. This can happen with blood transfusions.  Person with HIV to another person if she or he has a small cut on the skin, so that the HIV microbe can get into the body.  The HIV microbe can be transmitted from one person to another by syringes and needles during an injection. It can also be transmitted by other sharp objects that may pierce the skin accidentally, such as scissors, knives or razor blades.  A pregnant mother can sometimes transmit the HIV microbe to her baby in the uterus or during the delivery or after birth.

Explanation: prevention of HIV infection

The trainer explains that we can easily protect ourselves from getting the HIV microbe and AIDS in the following ways.  Use condoms during sexual intercourse. We talked about condoms yesterday, for family planning reasons, to prevent pregnancies. The condom is very important to protect a person from any sexually transmitted diseases and HIV/AIDS. Ask each TBA to practice how to put condom on.  Use gloves when coming into contact with the blood of another person. This is especially important for midwives, TBAs and other health staff. They should wear plastic gloves when they touch the blood of another person or wash their hands thoroughly with soap and water after touching blood.  Make sure that injections are only given with new syringes and needles. If you get a cut from a sharp object, like knives, scissors or razor blades, wash the cut thoroughly with soap and water. The trainer explains that anybody can get a test to show whether he or she carries the HIV microbe in the provincial capital. She shows the pictures and explains that: in every day life, a person with the HIV microbe is just like any other. It can not be transmitted by living in the same room, or by hugging or by sharing food or clothes. There is absolutely no need to stay away from a person with HIV or AIDS in every day life. The trainer coordinates the game of cards of how HIV is transmitted and how it is not transmitted. She puts all cards together. She asks one TBA to choose and put all cards of HIV transmitted and not transmitted separately. Then she shows each card and asks the group if the TBA's selection is right or wrong and why? The trainer distributes the handouts to the TBAs. She gives them time to look at the pictures. She asks what each picture means. She revises the modes of transmission of HIV and the ways of prevention.

Explanation : how HIV is NOT transmitted

Game

Revision

Session 20:
Materials:

Community work
Nutrition poster, breast feeding poster, poster of woman attending ante natal care. Newsprint, marker pens, tape. 1 hour Discussion, explanation, practice.

Lesson time: Training method: Lesson objective: Teaching steps Discussion on the situation in TBA’s communities

The TBAs are aware of their role of link persons between their communities and government health facilities.

The trainer tells the TBAs the topic and purpose of this session. She involves the TBAs in a description and discussion on the situation in their villages. She writes the main results on newsprint paper. In how many villages does a TBA usually work? Does she know most people in her village? How do most people earn their income? Do some go to other places to work or do they stay in their village? Who are the most important people in their villages? Why are they important? Is there a Village Health Volunteer or Feedback Committee in their village? What are the main problems in their villages? Are there many poor people? Why are they poor? How is health care mostly given in the village? (Shop selling medicines, nurse, midwife, health volunteer, local healer, monk, , outreach from health center?) The trainer writes all replies on the newsprint. If people can not find good health care in the village, where do they go? What kind of illnesses are most common in the village?

Explanation on links between community and government health services

The trainer explains that the TBA will be a very important person in her community if she can become a link person or “bridge” between her village and the health center. Like this she can make a good contribution towards better health of the people in her village. The trainer asks: what can the TBA do to become such a link person? Please give the TBAs enough time to think about this carefully and write the answers on the newsprint. After this discussion please explain the following points, if they have not already been mentioned by the TBAs: The TBA should:  Visit the health center often and maintain a good working relationship with all staff.  Work with the health center midwife when doing home deliveries.  Refer women with danger signs in pregnancy, labour and after delivery to

 
 

the health center. Refer sick persons from the village for treatment at the health center. Refer ALL pregnant women to the health center for ante natal care.
Remind mothers to bring their infants for vaccinations or obtain family planning services for themselves. If the health center staff do outreach in your village, they will appreciate your help in calling women and children to attend. Collect data on your deliveries and give them to the health center midwife regularly.

Explanation on health education

Role play

 You will be a good person to provide health education in your village. The trainer asks how the TBAs feel about giving health education? Who of them has done this already? Are some TBAs reluctant? If yes, why? What subjects would be suitable for health education? The trainer writes them on the newsprint. They should include: Nutrition in pregnancy and while breastfeeding Cleanliness Why the RACHA home birth kit is useful The importance of ante natal care Minor complaints in pregnancy Breast feeding How do we do health education? – Mainly from the TBA to individual women or in small groups. We shall talk about this in more detail at later follow up meetings. The trainer organizes role plays: A TBA chooses one of the above subjects and performs health education on it. This can be repeated with different topics as long as time is available. The group discusses the role plays and the trainer makes supportive suggestions for improvements if necessary. The trainer asks questions on all actions for linkages with the health center and encourages the TBAs to voice their opinion on each point.

Revision

Session 21:
Materials

Data collection
Poster of TBA data sheet covered with transparent plastic. White board marker pens. TBA data sheets, 12 pens, small cards, handouts. 1 hour Explanation, demonstration, practice games

Lesson time: Training methods: Lesson objective: Teaching steps General discussion Explanation: the reasons for data collection

The TBAs are able to record their deliveries correctly and know when to submit their data sheets to the health center.

The trainer asks which TBAs already give information to their health center midwives on their deliveries? How do they do it? When ? What is the reason for this? The trainer explains that it is important to give information to health center midwives about babies they have delivered and complications they have encountered. All this information from their communes will be compiled in large statistics, so that the government knows how many babies are born and what problems the TBAs have been met. RACHA needs to collect this information because the organization in USA who gives the money for this training wants to know how the TBAs are using the skills which they have learnt.

The trainer shows the large, plastic covered data poster to the TBAs. She asks Demonstration: what each picture could mean. Discussion till all pictures are clearly understood. entering data The trainer explains how the TBA should mark the data sheet after every delivery she has done. She makes up examples. Then she makes examples for the TBAs to write. For instance: A TBA has delivered a girl. It was a normal delivery. Mother and baby are well. A TBA has cared for a woman in labour. The baby (a boy) was delivered, but the placenta could not come out although the TBA tried all the things she learnt. The woman and baby were referred to the health center. A TBA delivered a woman of a boy. He was very small and did not breathe. He died. The mother had no problems. Each time one TBA goes up to the poster and marks the area under the correct pictures. All TBAs should have some practice in this. The trainer divides the group into three small groups. She gives each TBA a data Practice game sheet. She also puts 20 small picture cards into the middle of each group in a pile, upside down, so that the pictures cannot be seen. The TBAs in each group take turns in taking the top card off the pile, turning it up and saying what it

Revision with examples Collecting of data sheets.

means. Then they put this card on top of the picture of their data sheet. The person who has covered her datasheet with all the correct pictures first, wins the game. For revision the trainer makes up examples of deliveries and the TBAs enter them into their own data sheets. The trainer repeats again the method of data collection and the TBAs’ responsibilities. She distributes the handouts to the TBAs.

Session 22:
Materials Lesson time Training methods: Lesson objective: Teaching steps

Home Birth Kits
2 home birth kits, 15 pairs of clean gloves 45 mn Discussion, explanation, practice, role play

The TBAs know the value of clean deliveries with a home birth kit. They are able to use it correctly.

General discussion

If possible RACHA’s Home Birth Kit Monitor should participate in this session. The trainer tells the TBAs the topic and purpose of this session. She asks how many TBAs are already using the kit? How easy is it to use? Do the TBAs use all items in it? The trainer talks about the gaps of the TBAs' practice in previous times such as : delivery on an unclean surface, TBAs deliver the baby with bare hands (no gloves) and without washing hands, tie cord with unclean strings, cut cord with old razor or bamboo piece, apply pepper or incense stick ashes on the baby's cord etc. All these practices increase the rate of infection to mothers and babies, especially tetanus of newborn babies.

Demonstration and explanation 1. Introduce home birth kit 2. Importance

The trainer shows the home birth kit and asks What is the home birth kit ? She tells that it is a kit used for normal deliveries. One kit is used for one delivery. She asks what is a normal delivery? she tells that it is a natural delivery without any danger signs. She asks what are the advantages of using the kit? She tells that it ensures a clean delivery to reduce infection of mothers, babies, and birth attendants such as tetanus, HIV, hepatitis, and especially tetanus of newborn babies.
She asks what the kit contains? and how the materials should be used ? Showing each item, She tells that in each kit there are clean and enough items for normal delivery such as:

3. How to use

 

Plastic sheet: for putting under the mother to provide a clean surface and to avoid delivery on a delivery mat (unclean surface) which may cause infection. Soap powder and nailbrush: for washing hands and arms thoroughly before and after delivery

   

Practice

Role play

Clean gloves: The TBA puts them on to avoid infections. Cord strings : They are clean and are used to tie the umbilical cord. Blade: It is sterile and used to cut the umbilical cord. Gauze pieces: they are sterile and used to place under the cord when it is cut.  Gentian Violet: Put a little Gentian Violet on the gauze and apply it on the baby’s cord. The cord should not be covered and nothing else should be put on the cord. Always keep it clean and dry. The trainer shows the TBAs how to put the gloves on. She gives each TBA one pair and supervises them while they practice. The trainer organizes a role play with two TBAs (woman in labour and TBA) where all items of the kit are used. Discussion The trainer emphasizes that this kit is important for clean deliveries. However, the TBA must still carefully look for danger signs and refer the woman as soon as any danger signs appear.

Session 23:
Materials: Lesson time: Training methods: Lesson objectives:

Revision
All materials of the training workshop should be available, though not everything may be used. Answer and question cards for revision game. 3 hours Question and answers, discussion, explanation, role plays, demonstrations. The TBAs are aware of the main issues taught in the workshop and take appropriate action.

The trainer revises the main issues of this workshop: Danger signs in pregnancy Danger signs during labour and delivery Danger signs after delivery Refer every pregnant woman for ante natal care How to refer a woman. The five cleans Normal labour and delivery Post partum haemorrhage Community collaboration, including the role of the TBA Revision can be done by looking at the pictures in the TBA’s books together and asking questions. Posters, as well as the doll and pelvis and other training materials can be used for explanation. If there is time a role play can be done and hand washing can be practiced. The trainer asks the TBAs to repeat the main points till she is satisfied that the TBAs have appropriate knowledge. She clarifies any misunderstandings which may become apparent.

Revision Game: The pink cards of the revision game are spread on the table or floor, upside down so that the writing cannot be seen. The trainer keeps the corresponding white answer cards. One after each other, each TBA picks up one pink question card and reads the question on it out to the group. If the TBA is shy to read or cannot read, the teacher will read for her. The TBA answers this question. Other TBAs add to the answer, if it is not complete. The trainer probes for more details. Finally the trainer reads the answer on the white card and explains anything that the TBAs may not have mentioned. Then the next TBA picks up a pink card and the game begins again.

Session 24
Materials: Lesson time Method: Lesson objective: Session steps: Explanation Post-test papers for trainer 45 minutes Individual interviews

Post-Test

The trainers have obtained information on TBAs’ technical knowledge after the completion of the training.

The lead trainer explains that it is necessary to perform a short test on the knowledge of TBAs, similar to the one done at the beginning of the training. This is to help the trainers evaluate the course. The results are confidential, so the TBAs do not need to worry at all. Each trainer works with one TBA at a time. She sits with her in a quiet place where others can’t hear. She reassures the TBA and makes her comfortable. Then she asks each question from the test paper and gives the TBA enough time to consider the answer. If the TBA does not understand the question the trainer explains it, but does NOT give hints towards an answer. The trainer records the answer on the test sheet. All TBAs are to be tested in that manner.

Test

Revision Game Questions
1. Which foods are good for pregnant and breastfeeding women? Which ones should be avoid? 2. What are danger signs in pregnancy? 3. When should the TBA wear clean gloves? 4. During labour, what the TBA should not do? 5. Normally, how much blood loss after delivery? 6. What are the signs of placenta separation? 7. What are danger signs during labor and delivery? 8. What are danger signs for mother after delivery? 9. What are danger signs for newborn baby? 10.If the placenta does not come out for haft an hour, what should the TBA do? 11.If the placenta does not come out for an hour, what should the TBA do? 12.After delivery of placenta, if the mother has severe bleeding, what should the TBA do quickly? 13.When should we start breastfeeding a baby? why? 14.What are the 5 clean? 15.How is HIV transmitted? 16.How to prevent HIV transmission? 17.When should the TBA send their data to HC midwife? 18.Why should you send every pregnant woman to the midwife for antenatal care? 19.When you refer a woman because of a danger sing, what do you have to do?

Revision Game Answers
1. The good nutrition for pregnant and breastfeeding women : any kind of meat or fish, eggs, milk, any kind of vegetables and fruit. The same foods are good for pregnant women and breastfeeding women ! - Alcohol, cigarette, medicine without prescription should be avoid. 2. Danger signs in pregnancy are: fever, edema/convulsion, bleeding, premature rupture of membrane, malpresentation (breech or transverse) 3. The TBA should wear gloves when she can see the mother's perineum bulging/a small bit of the baby's head at the vulva. 4. During labour, the TBA should never do the following: - Never give injections or other medicine - Never put your fingers into the vagina - Never push on the mother's abdomen 5. Normally, after delivery, the woman loses approximately as much blood as would fit in one can of milk. If more than this, it is dangerous. 6. The signs of placenta separation : - A small gush of blood comes from the vagina - More of the cord can be seen on the outside of the vulva 7. Danger signs in labor and delivery : - Severe bleeding - A hand, foot, or the baby's cord appear in the vagina - Prolong labour - Green amniotic fluid - convulsion 8. Danger signs for mother after delivery : - Retained placenta - Severe bleeding - The uterus is not contract/descended - Fever - The breast is red, hard and painful

9. Danger signs for newborn baby : - The baby is not breathing normally - The baby's cord is red or covered with pus - Fever - Baby is not sucking, or not sucking well - Conjunctivitis 10. If the placenta does not come out for haft an hour, the TBA should do: - Put baby to breast - Ask the mother to squat down and push - Ask the mother to cough, sneeze or vomit - Ask the mother to pass urine 11. One hour after delivery, if the placenta does not come out, the TBA should call a trained midwife or refer the mother to the HC immediately 12.After delivery placenta, if the mother has severe bleeding, the TBA should make preparation to refer immediately and on the way she should do: - Lay the mother flat and raise her feet on pillows. - Rub uterus - Put baby to breast - Give her something to drink - Ask the women to pass urine 13.We should start breastfeeding as soon as the baby is born, even before the placenta is delivered, because : - It makes the mother's uterus contract and reduces bleeding - The very first, thick and creamy milk is very good for the baby - It protects the baby from infection 14.The 5 cleans : - Clean delivery set - Clean cord tapes - Clean surface for the mother to lie on - Clean hands with soap and water - Clean vulva of the mother with boiled water 15.HIV is transmitted through: - Sexual intercourse

- Blood transfusion/contact with blood - Injections are given with syringes and needles without sterilization - A pregnant mother to her baby 16.How to prevent HIV: - Sincere with their wife/husband - Use condoms during sexual intercourse with their partners - Use gloves when contacting with blood - Never give injections with syringes and needles without sterilization 17.The TBA should send their data sheet to the HC midwife every month 18.The TBA should send every pregnant woman to the midwife for antenatal care because she can find out whether the woman is healthy or not, and if she finds problems, she takes the correct action. At an ANC session the midwife do the following : - Checks the woman's abdomen, to feel how the baby lies - Listens to the baby's heart beat - Takes the mother's blood pressure - Sends the woman for TT vaccination - Checks for anemia and gives iron tablets - Provides health education 19.When referring a woman because of a danger sign, the TBA should do: - Explain clearly to the mother/family about the referral problem - Go with the mother - Take baby with her if the problem occurred after delivery