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Introduction and BreastfeedingPromoter Flipchart

Module 1 of 6

Understanding the Lesson Plan

Each lesson begins with objectives. These are the behavior, knowledge and belief objectives that are covered in the lesson. Make sure that each of these objectives is reinforced during the lesson. There are four types of objectives. Each is described below.

Our main goal is for caregivers to practice healthy behaviors. For this reason, most objectives are behavioral objectives written as action statements. These are the practices that we expect the caregivers to follow based on the key messages in the flipchart.

A few objectives are knowledge objectives. We want mothers to be able to name the danger signs as well as the five ways that diarrhea-causing germs are transmitted. These are things that the caregivers must memorize during the lesson, using the pictures as a reminder.

Each lesson contains one belief objective. We know that beliefs and attitudes affect our practices. Many times it is a person’s inaccurate belief or worldview that hinders them from making a healthy behavior change. In this module we are reinforcing the belief that humans have been given dominion (authority) over all living creatures by God. Knowing this, participants understand that they are not meant to be overcome by sickness, illness and poor health. The dominion principle helps participants to be in right relationship with God and creation.

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

Under the objectives, all of the materials needed for the lesson are listed. The facilitator should make sure to bring all of these materials to the lesson. Materials marked with an asterisk (*) are required for the lesson’s Activity. These materials will be organized by the Activity Leader. See below for more information.

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

1 See http://barrieranalysis.fhi.net for more information.

http://barrieranalysis.fhi.net/

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

Following the game is the attendance and troubleshooting section. All facilitators will take attendance. The troubleshooting questions only apply to facilitators (promoters) training others.2 The promoter follows up with any difficulties that the Mother Leaders had teaching the previous lessons. Refer to the role play in Module 1, Lesson 1 for more information.

Next the facilitator opens the flipchart to the first picture of the lesson. He or she reads the story printed on the back of the flipchart, adding more details and descriptions as desired. The story reinforces a behavioral determinant or reason found to be important for behavior change in your region. Use the story, discussion and the following flipchart pages to reinforce the key determinant noted in the text.

The story in each lesson is followed by discussion questions. These questions help the facilitator to find out the caregivers current practices (related to the lesson). This section is marked by the A (ask) in the ASPIRE method.3 This section is meant for discussion, not for teaching. Be sure to let everyone voice their opinion.

The second, third and fourth picture in each lesson are for teaching the key objectives of the lesson. After turning to the second flipchart page [the S (Show) - in ASPIRE], ask “What do you see in this picture?” Let the participants respond and describe what they think the flipchart pictures are telling them.

Next, explain the key messages written on the back of the flipchart. The key messages also appear as captions on the flipchart pages. Be sure to explain each picture using the additional bullets printed on the back of the flipchart (or in the lesson plan). The lesson plan also contains additional information for the trainer. For example, in Lesson 4 more information is given to about the different types of parasites and the symptoms for each. The additional information does not need to be discussed during the lesson unless it directly relates to questions by the participants.

2 In the Tubaramure program, paid staff are called promoters. The role of the promoters is to train Leader Mothers to facilitate lessons with their neighbors. A few exercises, noted above, are only for promoters and do not need to be used by the Leader Mothers when sharing with their neighbors.3 For more information about the ASPIRE method review Lesson 2.

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After the fourth picture of the lesson, is an activity. Activities are “hands-on” exercises to help the participants understand and apply what they have learned. Most of these activities require specific materials and preparations. The needed materials (those with an asterisk in the materials section) are the responsibility of the Activity Leader (see below). If no activity leader has been selected, the facilitator is responsible to bring these materials.

The Activity Leader meets with the facilitator ten minutes before each lesson to discuss the needed materials for the next lesson’s activity. The Activity Leader is responsible to talk with the others (Leader Mothers or neighbors) during the “Attendance and Troubleshooting” to organize the materials needed for the next meeting, asking mothers to volunteer to bring the items. The facilitator will lead the activity, but the Activity Leader will support her by organizing the volunteers and aiding the facilitator as needed during the activity. A new Activity Leader is elected for the next module during the fifth lesson.

After the activity, the facilitator completes the P and I of the ASPIRE method. The ASPIRE method is used to reinforce participatory methods of teaching. It is explained in detail in Module 1, Lesson 2.

In the probe section the facilitator asks if there are any obstacles that may prevent the caregivers from trying the new practices. They discuss these obstacles and then move to the next section.

The facilitator informs the caregivers of ways to overcome the concerns that are mentioned. The facilitator gives more information or a different perspective to help the caregivers understand how to move forward.

Next is Practice and Coaching. This section is required for the training of Mother Leaders. We want to make sure that they understand the material and can present it to others. In this activity, the promoter will observe Leader Mothers as they practice teaching with the person sitting next to them. The Promoter will coach those who are having difficulty.

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

The facilitator requests a commitment from the Mother Leader (or caregivers) to begin practicing the new practices they have discussed. If they agree, the caregivers should make a verbal commitment. It is up to the caregivers to make a choice. They should not be forced to make a commitment if they are not ready.

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In the last section the facilitator examines (or requests an update on) the Mother Leaders’ (or caregivers’) commitments from the previous lesson. Were they able to keep their commitments? Have they been practicing the behaviors they learned at the last session? The facilitator offers support and encouragement to help them keep and maintain their commitments.

All lessons follow the pattern described above. Lessons can be adapted as needed to fit the needs of your care group. Lessons should not exceed two hours in length although some lessons may take longer than others. The suggested time for each section is listed below.

Section name Time needed for this sectionGameAttendance and TroubleshootingStory and Ask (picture 1)Show and Explain (picture 2)Show and Explain (picture 3)Show and Explain (picture 4)ActivityProbeInformPractice and CoachingRequestExamine

10 minutes15 minutes10 minutes5 minutes5 minutes5 minutes15 minutes10 minutes5 minutes20 minutes10 minutes15 minutes2 hours

AcknowledgementsHanold, Mitzi J. and Davis Jr., Thomas P., (2009) Introduction and Breastfeeding. Washington DC. Food for the Hungry (FH), made possible through support provided by the Office of Food for Peace, Bureau of Democracy, Conflict, and Humanitarian Assistances, and the U.S. Agency for International Development under the terms of Award No. Award No FFP A-00-08-00086. The opinions expressed herein are those of the authors and do not necessarily reflect the view of the U.S. Agency for International Development.

CreditsSeveral illustrations adapted from Where There is No Artist, by Petra Röhr-Rouendaal, ITDG Publishing (October 1997). Cover illustration provided by Octavio Gonzalez and Petra Rohr-Ruoendall.

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Lesson 1: Care Group Orientation

Caregivers will be able to identify those involved in making the program a success including the Community Development Committee, Food for the Hungry, USAID, and other donors.

Caregivers will be able to list the main objectives of the program o Learn how to keep the mother healthy while pregnant and lactating. o Learn how to best feed, and care for children from 0-23 months.o Learn how to prevent, diagnose and manage childhood disease that

causes malnutrition. o Learn how to keep our water, food, and bodies clean to protect our

families from germs that cause illness. Leader Mothers will be able to define their role in the program:

o Who is Leader Mother? o What does a Leader Mother do? o How often do they Leader Mothers meet in care groups? o Who takes over the care groups when the program if finished?

Caregivers will believe: I CAN change. Change is possible.

Materials: 1. Attendance Register 2. Three copies of the role play at the end of the lesson.

1. Game: Getting to Know You – 10 minutes

1. Ask Leader Mothers to talk to the woman sitting next to them to find out about their family (how many children, how old are they, what are their names, etc). Finally, ask what they hope to learn from being a Leader Mother.

2. In a large group, ask each Leader Mother to introduce her neighbor until everyone has been introduced.

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2. Attendance and Troubleshooting – 10 minutes

1. Promoter fills out attendance sheets for each Leader Mother and neighbor group (beneficiary group).

3. Show: Ask the caregivers to describe what they see in the picture on page 5.

? What do you see in these pictures?

4. Explain: Share the key messages using flipchart pages 4 and 5.

This program is your program. With your experience, talents, and time we can work together to bring improved health in your community.

The group of people at the front is the Community Development Committee. They help to manage this program. They have selected each one of you to be a part of the program.

This symbol stands for USAID, a group within the United States government. They have given this community funding for (X years) to help us to train Leader Mother and Promoters in your the communities. This training will give you the knowledge that you need to succeed.

This symbol stands for Food for the Hungry (FH).

? Have any of you worked with FH before?

FH is a Christian organization motivated by the teachings of Jesus to help others. We have been working in [country] for [x years]. We do our work by helping leaders, families and churches to overcome spiritual and physical poverty.

Explain other donors as needed.

Program Focus (Picture 1.2) - 5 minutes

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The program focuses on improving the nutrition of pregnant and lactating mothers and the nutrition of their children under age two.

It gives mothers, pregnant women, and other caregivers information to stay healthy and well nourished.

When mothers are healthy, their children are more likely to be healthy too.

The training not only teaches mothers how to be strong during and after pregnancy, but gives information about caring for children during the first two years of life.

Infants and children under the age of two are most vulnerable to sickness, malnutrition and death. Children who live beyond age two are much more likely to live a full life.

Many children die in our villages before age two. If children are strong in the first two years, they are more likely to be healthy for many years in the future.

? What are some of the health problems that you see among pregnant women and children under age two?

Encourage discussion. Paraphrase the ideas that the participants have given.

? Do you think it’s possible that these things could change? What are some things that you have changed in your life?

Facilitator should begin with an example. Use an example of something that you have changed about yourself rather than how you changed someone else. For example, “I changed the way that I fed my children after learning about the importance of porridge,” or “I changed where I go when my child has fever because I changed my beliefs about the causes of malaria.” Encourage discussion.

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Just as we have seen changes in our own lives, we can also expect changes when we work together.

Program Objectives (Picture 1.3) - 5 minutes

7. Show: Ask the caregivers to describe what they see in the pictures on page 9

? What do you see in these pictures?? What differences do you see between the mothers and

their children?? Does it appear that one of these women has more

money than the other?? Do you think it is possible that both of these women

could be living in the same village?

8. Explain Share the key messages using flipchart pages 8 and 9.

In this picture, you see two women, who have made different choices about feeding and caring for their children. These choices have impacted their health and the health of their children.

Mary has made healthy choices. The other woman has made different choices. Her health and those of her family has suffered from these choices. We will be learning from the mother on the left. Her name is Mary.

From Mary, will learn how to:o Stay healthy when pregnant or breastfeeding so that our

breasts are full.o How to provide and care for children from 0-23 months.o How to prevent child illnesses like malnutrition, diarrhea and

malaria, diagnose these problems, and treat them.o How to keep our water, food, and homes clean so that our

families will be healthy. The second woman’s name is Ruth. This woman will be learning with

us as we go. By the changes that she makes in her life, we will learn how to make

healthy changes too.

Care Groups (Picture 1.4) - 5 minutes

9. Show

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Ask the caregivers to describe what they see in the picture on page 11



The teacher in the first group of women is called a Promoter. The people sitting and learning from the Promoter are Leader Mothers. This is how the training will be passed down.

Each Lead Mother from the care group will visit other caregivers in her community. She will visit ten houses where Caregivers have children 23 months of age or younger.

She visits with each family once every two weeks, sharing the messages she learned from the promoter.

She educates mothers (and other family members who want to listen such as husbands, grandmothers, mother-in-laws and older children). She shares with them using a small flipchart.

Sometimes the Leader Mother is observed by her supervisor to make sure that she is sharing well.

She also asks the families about their any child health problems and concerns. The Leader Mother works with the Promoters and the Community Development Committee to solve these problems and concerns.4

For two years, we will work together to equip Leader Mothers to solve health problems in the community. After two years, you as Leader Mothers will be ready to work without the help of Food for the Hungry. You will be well known in the community for the help that you have given. You will be ready to lead the program on your own.

11. Activity: Role Play — 15 Minutes

1. Ask for three volunteers to act out the role play at the end of this lesson with you.

4 The Community Development Committee elects new Leader Mothers, helps the Leader Mothers to persuade people to make changes in their practice, warns Leader Mothers if they are not fulfilling their duties, replaces Leader Mothers if they leave or resign, and resolves problems in the community (examples include lack of respect for the Leader Mother or difficult to change practices). Leader Mothers should bring problems to the committee for assistance. For example if people are not building latrines then the Leader Mother should bring this problem to the committee and together make a plan to encourage change.

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2. Give one copy of the role play to each volunteer.3. For low literate audience, you might also consider asking another literate

volunteer to read the role play. Each volunteer should listen and then act out each sentence after it is read.

? What did you see in this presentation?

Encourage discussion.

The Leader Mothers must meet with all of their mothers every two weeks. If they do not meet with each woman every two weeks on a regular basis, they may be replaced.

It is the Leader Mothers’ responsibility to give a report of her meetings with her neighbors.

The Promoter asks about problems with the meetings, and helps the mothers to find solutions.

If there are problems encouraging a new practice a few suggestions are given:

o Ask other Leader Mothers what they have done to help mothers change.

o Speak with other members in the household about the new practices.o Have caregivers who are practicing the healthy practice come and

share their experiences with the mother.

? What do you think will help the Leader Mother to be a successful Leader Mother? What kind of character should she have?

Encourage discussion. She is willing to learn new things and come to all of the trainings. She communicates easily with others. She listens and respects others. She understands helps others to try new practices. She is committed to continue helping mothers even after all the training is

complete. She believes that change is possible and encourages other mothers to believe

too.

12. Probe — 10 minutes

? What do you think about these ideas? Do you think you will be able to be Leader Mother? Is there anything that might prevent you from doing these things?

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

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

13. Inform 5 minutes

Help find solutions to their concerns. If a woman offers a good solution to another woman’s concern, praise her and encourage other mothers to consider using this solution when they talk with others.

14. Practice and Coaching ─ 20 minutes

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

2. One Leader Mother will share the teachings from the first two pages of the flipchart. After ten minutes, the Leader Mothers will switch roles. The other Leader Mother will share the teachings from the third and fourth flipchart pages.

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

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

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

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

15. Request – 10 minutes

? Are you willing to do commit to being a Leader Mother? Get agreement from each Leader Mother.

Role Play: Promoter meeting with Leader Mothers You need three volunteers each with a copy of the role play. The volunteer Leader Mothers should sit in a small circle in front of the Promoter (just as they would sit in a care group meeting). The Promoter should be sitting with an

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attendance register and pen on her lap. A flipchart is sitting nearby. Explain that this meeting in several months from now (it is not a representation of the first meeting of Leader Mothers and the Promoter).

Promoter: Greets all of the Leader Mother. Let’s begin today’s meeting by discussing the meetings that you’ve had with your beneficiaries. We will start with attendance. Promoter: Promoter checks the register in her lap and then calls the name of Leader Mother 1. How many mothers did you visit since our last meeting?Leader Mother 1: I visited all of my mothers. But one mother was away visiting relatives. So I did not see her. She has returned this week. I will teach both lessons to her during the next two weeks.Promoter: You visited all mothers, but one was not at home. You plan to teach her both lessons at your next meeting. She makes a mark on the register. Leader Mother 1: Yes. That is right.Promoter: Looks at her register and calls the name of Leader Mother 2. How many mothers did you visit since our last meeting?Leader Mother 2: I met with each of my mothers. Promoter: She writes on the register. You taught lessons to all of your mothers. Great. Leader Mother 2: Yes. Promoter: Promoter checks the register in her lap and then calls on Leader Mother 3. How many mothers did you visit since our last meeting?Leader Mother 3: I asked all of the women to come to one meeting together. Only half of them came.Promoter: You know that it is your responsibility to visit each mother. If it is difficult for all of them to come to one meeting, then you need to meet with them one-on one. You must make sure that you teach all of the mothers that you are given. Leader Mother 3: Yes. I know. Promoter: We can talk after the lesson. I can help you with some ideas for meeting with the mothers. It is important that you visit all mothers.Leader Mother 3: Yes, that is good. Let us talk after the lesson. I do not want to be replaced. Promoter: Ok, we will talk at the end of the lesson. Now that we have taken attendance, tell me about your meetings. How did your visits go? Did the women understand the teachings on exclusive breastfeeding?Leader Mother 1: You know that many people here believe that water and other foods must be given to the infant when they are born.5 Some mothers did not want to commit to changing their ways. They found the teaching very difficult. Promoter: You were teaching about breastfeeding and some mothers had trouble accepting the message. What did you do? Leader Mother 1: I told them that it was okay if they did not feel ready to make a commitment to exclusive breastfeeding. I told them that I would continue meeting with them, and that they could talk to other mothers and make a decision later. Promoter: (Speaking to Leader Mother 2 and 3) Did any of you have these troubles? 5 Adapt or insert other common “harmful beliefs” or obstacle to breastfeeding from your barrier analysis findings.

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Leader Mother 2: Yes, one mother in my group is giving water and other foods to her infant before it is time. So I asked about the health of her infant. Her infant had been very sick. I asked her to try breastfeeding only to see if her infant’s health and weight improves. She said she would try it. Promoter: So, you asked the mother to try out the new practice, and see if the baby’s health improved. That is a very good idea. [Turning to Leader Mother 1] You may consider giving this same advice to the woman you mentioned the next time that you meet.Leader Mother 1: Yes I will try that. I will also see if I can get other mothers who exclusively breastfeed to talk with her. When she hears from these mothers and sees the health of their infants, she may be ready to listen. Promoter: You may also speak to the others in her household, the mother-in-laws and the husband if they will listen. Once the whole family understands it may be easier for the mother to try something new. Leader Mother 3: Yes. That is good. Several other family members joined the meeting that I had with the mothers. It was very helpful. Promoter: [To Leader Mother 3] Yes, it is very good that you are encouraging others to join. [To the group] Any other problems? Leader Mother 2: The mothers that I met with were very happy with this information. They said that it was so good and they wished that they had known sooner.Promoter: Good. Yes, as we continue to share with women in our community, we hope that they too will share with their neighbors and that many children will be healthy and strong. Let’s now begin with today’s lesson. To begin today’s lesson we will hear a story...

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Lesson 2: Educational Methods

Leader Mothers will be able to identify the different steps in the ASPRIRE teaching method.

Leader Mothers will be able to share a message using the flipcharts and the ASPIRE teaching methods with someone else in the Care Group.

Leader Mothers will demonstrate correct teaching and persuasion techniques. Leader Mothers will believe: I CAN change and help other to change

Materials:

1. Attendance Registers 2. Three copies of the role play.

1. Game: Professor Glasses — 10 minutes

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

I will tell you what to do, but you must do it on your own. I won’t answer questions, or tell you if you are doing it right. You must listen.

Press and hold the tips of your thumb and first finger together on each hand. Your fingers should form two small circles on each hand.

Keep your fingers pressed together. Now touch the two circles together from each hand so that they are joined in front of you.

Next touch your remaining six fingers under your chin, so that the palms of your hands are facing away from you.

Keeping your fingers under your chin, move the palms of your hands towards your eyebrows, until you can lay your thumbs across your eyebrows.

? How did you do?

Let’s try it again. This time I will show you.

6 This game can be substituted with another game as needed. Leader Mothers need to know how to do this activity. Practice with them. If it is too difficult, use a different game.

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Read the same instructions again. Answer questions. Help those who are having trouble. Show them with your hands what they should do for each step.

? What can we learn from this exercise?


People learn best when they can see and hear how to do a new thing. People learn best when they practice the new thing with someone who has

done it before. In our program we will be sharing new skills and new practices. We have to

show them and help them to practice the new skills. We can help caregivers learn healthy practices, and try to persuade them, but

they must make the final choice to commit to the new practice or not.

2. Attendance and Troubleshooting –10 minutes

4. Promoter fills out attendance sheets for each Leader Marynd neighbor group (beneficiary group).

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

6. The Promoter (and other Leader Mothers) helps to solve the problems that are mentioned.

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

8. Promoter asks the group’s Activity Leader7 to discuss the needed items for next week’s activity and solicit volunteers.

Ask and Show (Picture 2.1) – 5 minutes

3. Show: Ask the caregivers to describe what they see in the pictures on page 13.

7 The Activity Leader should arrive ten minutes prior to each care group meeting to get the description of the activity and the list of needed items from the promoter.

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4. Explain: Share the key messages using flipchart pages 12 and 13. To help everyone remember the skills for teaching, we will use one word to

help you remember. The word is “ASPIRE”8 Each letter in this word stands for something that we must remember to do when teaching others.

The first image represents ASK.o Most lessons begin with a story about Ruth. Read the story on

the back of the first page of the lesson, showing the image to the family. Then ASK the mother (and family) about their current practices.

o For example, “Mother B doesn’t know how many times to breastfeed. Are you breastfeeding your child? How many times do you breastfeed your infant?”

o You should listen to the questions that I use with you during each lesson. Use the same questions when you meet with your neighbors.

The second image stands for SHOW.o When you see this picture you will SHOW the mother (and

family) the next page of the flipchart. The second page usually is a picture of Mary.

o Ask the mother (and family) what they see in each picture. For example, “What is the mother in this picture doing?

o Then explain what this picture means for the health program in our community.

o Everything that you should say is written on the back of the flipchart picture.

Probe and Inform (Picture 2.2) - 5 minutes


8 This word should be changed into four or five words that begin with the same letter in the local language. It will help mothers to remember the process. An example using F in English is as follows: FIND out what the mother believes. Use the FLIPCHART to explain. How does the mother FEEL about these practices? FIND a solution to the problems that she mentioned. FOLLOW up with a request for a commitment. FILL out the Model Family poster if new practices have been completed. Choose a letter and local words that Leader Mothers can easily remember.

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The first image represents PROBE.o After you have shown them all four pages of the lesson, ask

the family about obstacles that may prevent them for trying the new practice.

o For example, “What do you think about this suggestion? Is there anything that might make it difficult for you to breastfeed on demand day and night?”

o Be sure to listen to the concerns that the family mentions. The second image represents INFORM.

o Suggest ways that the caregivers can overcome the problems and concerns that they mention. Encourage change.

o For example, “You mentioned that your mother-in-law may disapprove of breastfeeding day and night. Could you talk with her about this? Is there someone else who could try to convince her?”

Request and Examine (Picture 2.3) - 5 minutes




The first image represents REQUEST.o Ask the mother (and family) if they would like to commit to

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this healthy practice.o For example, “We learned about breastfeeding on demand day

and night. Would you like to commit to this new practice today?”

o Ask the mother to make a verbal commitment. Remember it is her choice whether she wants to commit or not.

The next image represents EXAMINE.o Go back to the last lesson. Review the main practices that you

discussed. Ask the mother (and family) if they have been doing these practices.

o For example, “Let’s review the last lesson. Have you been to the health clinic to receive your iron and vitamin A supplement? Have you added nutrient rich foods to your diet? Have you been eating an extra portion each day?”

Review the ASPIRE steps again. Ask for volunteers who can explain the meaning of each word.

Now let’s watch another role play to see what happens when a Leader Mother visits a mother in her home. This role play takes place after several lessons have been taught. Listen for the ASPIRE steps.

9. Activity: Role Play—15 Minutes

1. Ask for two volunteers to act out the role play at the end of this lesson with you.

2. Give one copy of the role play for each volunteer.3. For low literate audience, you might also consider asking another literate

volunteer to read the role play. Each volunteer should listen and then act out each sentence after it is read.

? What did you see in this role play?

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

Leader Mother first inquired to see if it was a good time to visit. Leader Mother asked about the health of the children. Leader Mother used the ASPIRE method. Leader Mother often paraphrased what the mother said. This helps to clarify

and confirm what the mother has said. She did not force them to make a commitment. She mentioned the benefits

of adopting the practices.

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Ask the Leader Mothers to mention each letter in ASPIRE and what was said by the Promoter.

o Ask: “Have you ever done this in the past? What do you think about this idea? Have you done this with your other children? When do you usually start giving your children other foods and liquids?”

o Show: “Let’s compare the teachings from our lesson to the practices that you are used to doing. We will begin with a story about Mary....”

o Probe: “What do you think about this lesson? Is there anything that might make it difficult for you to only give breastmilk for the first six months?”

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

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

o Examine: Have you given only breastmilk for the last few weeks? Do empty one breast before giving the infant the other breast? Have you been feeding your child whenever she shows signs of hunger?”

10. Probe—10 minutes

? What do you think about these ideas? Is there anything that might prevent you from using the ASPIRE method and sharing with others?

Ask mothers to talk to a woman sitting next to them for the next five minutes. They should share any personal concerns that they have with these messages. Together they should try to find solutions to these worries and problems. After five minutes, ask the Leader Mothers to share what they have discussed.

11. Inform—5 minutes



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13. Request ─ 10 minutes

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

Ask each mother to say aloud the new practice (or small step towards a new practice) that she will try during the next two weeks. Each mother can choose the practice that is most important to her.

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Role Play: Leader Mother Visiting a Mother in her Home A mother is sitting with her mother-in-law preparing a meal. The Promoter (acting as the Leader Mother) enters the compound carrying a flipchart with her.

Leader Mother: Greetings to you and your family. Is this a good time to talk? Would your husband or others in your family like to join us? Mother: My husband is not here. But my mother-in-law is here with me. She will listen too.Leader Mother: As you know I am an elected community volunteer, a Leader Mother, and I have been receiving training to help families raise healthy children. Mother: Yes. We are very glad that you have come. Leader Mother: How is your family; are your children well? Mother: Yes. We have heard your teachings from our last meeting. When my child was born last week, I put her to the breast immediately. She is strong and healthy. For this we thank God. Mother: I am glad that she is doing so well. Have seen the benefits of breastfeeding immediately?Mother and Mother-in-Law: Yes.Leader Mother: Last week we discussed caring for infants. Let’s see what Mary and Ruth are doing this week… Leader Mother: Leader Mother pretends to show a flipchart picture. “Ruth’s infant was born three weeks ago. He is small, but is growing a little. Ruth breastfeeds him, but she is worried that he is not getting enough nutrition. She wonders if he would grow more if she gave him a bottle.” What do you think about Ruth’s situation? Have you felt this way before? Mother: In our family, we always give only breastmilk for the first month of life. Then we start giving water. At three months, we give porridge to help the child sleep through the night. 9

Leader Mother: So I hear you saying that you believe that breast milk is very good for infants. You usually start giving an infant liquids at one month and other foods at three months. Mother and Mother-in-Law: Yes that is right.Leader Mother: Okay. Let’s compare your actions with the practices of Mary. Promoter explains that she has now gone through each picture with the participants. She is skipping the flipchart teaching so she can demonstrate the rest of the ASPIRE process.Leader Mother: What do you think about this lesson? Is there anything that might make it difficult for you to exclusively breastfeed for the fist six months of the child’s life? Mother-in-Law: I have heard from your story that Mary gave only breastmilk for the first six months. Then at six months she added foods. I have never heard such teaching before. Mother to Mother-in-Law: You are right, we have never heard such teaching, but it is true that infants don’t need other foods or drink before they are six months old. Even some women in our villages wait to give food or other liquids until the child is six months old. Mother-in-Law: Yes. This is true. Some women say that giving food earlier gives the child diarrhea.

9 Insert other “incorrect” beliefs about breastfeeding practices from Barrier Analysis surveys as appropriate.

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Leader Mother: So it sounds like although many mothers give foods early, some wait to give foods to prevent the child from getting illnesses. Mother-in-Law and Mother: YesLeader Mother: So what do you think? Do you think it is possible that waiting to give foods or drink might prevent illness?Mother: I think it may be true and we have heard your teaching and the story of Mary. She is very wise and her children are much stronger than the other mothers. How can we be sure that our children are growing well with only breastmilk?Leader Mother: The nurse at the health post can read the growth chart and show you that the child is growing well. Would you be willing to try to exclusively breastfeed your infant until six months, and then begin slowing adding foods?Mother: Yes, it is possible. We will talk to our family and make a decision with them before your next visit.Leader Mother: Okay. I will ask you at my next visit. Now let’s examine what you have done since my last visit. You said that you put the infant to the breast immediately after she was born. Is that right?Mother: Yes. She is very strong and healthy now.Leader Mother: That is wonderful. You are trying new things. Have you given only breastmilk for the last few weeks? Mother: Yes. Leader Mother: Do empty one breast before giving the infant the other breast? Have you been feeding your child whenever she shows signs of hunger?Mother: Yes. Yes.Leader Mother: You are doing so well and I can even see that you child is happy and healthy too. Mother-in-Law and Mother: Thank the Leader Mother for coming.Leader Mother: Schedules a time for her next visit, thanks the women and leaves.

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Lesson 3: Maternal Nutrition

Caregivers will be able to list the things that pregnant and lactating mothers need to stay healthy (and keep their infants and children healthy)

o Increased feeding for good weight gain o Eating a variety of foods with many different colorso Eating nutrient rich foods o Increased iron consumption (iodized salt)o Antenatal visit for iron supplement

Caregivers will discuss importance of equal food distribution (during pregnancy and for children) for women and children in the family.

Caregivers will believe: God has given us gifts (nutritious foods and resources) to keep our bodies and our developing children healthy.

Materials

1. Attendance Registers2. A container of iodized salt

1. Game: Hello Hello — 10 minutes

1. Ask the Leader Mothers to stand in a circle. 2. Select one Leader Mother. Ask her to walk around the outside of the circle

and tap someone on the shoulder. 3. That person walks the opposite way around the circle, until the two people

meet. They greet each other three times by name. 4. The two Leader Mothers then walk quickly back to the open spot, walking in

opposite directions around the circle. The person who fills the spot first is the winner.

5. The other Leader Mother then walks around the outside of the circle and chooses someone to tap.

6. Repeat the game until everyone has had a turn.

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

2. Attendance and Troubleshooting — 10 minutes

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Frightened of Delivery (Picture 3.1) - 5 minutes

3. Story Read the story on page 18 of the flipchart.

Ruth is 27 years old and pregnant. She has two children and is getting ready for her third child. She has not been feeling well during this pregnancy. Today, she has a headache. Her body is aching. She has eaten less for the last few months because she is frightened of having a difficult delivery. She hopes this will make the infant easier to deliver. She wonders if there is something that she could do help her pregnancy go well. Her other children were very small and are often sick. The labor was very long for both of her children. She wishes that she knew how to make her children healthier.

4. Ask Read the questions on page 20 of the flipchart. Encourage discussion. Don't correct "wrong answers." Let everyone give an

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

? How would you describe this mother’s pregnancy?? Is it going well? What are some of the problems that Ruth

faces?

Today, we are discussing the health of mothers during lactation and pregnancy. We will observe Mary, a neighbor of Ruth. We will compare your practices with the things that Mary has done.


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? What are the things that pregnant mothers should eat to make sure that they are healthy during pregnancy and lactation?

? Should they eat more or less?

Increased Feeding (Picture 3.2) - 5 minutes



6. Explain Share the key messages using flipchart pages 20 and 21.

Pregnant women should eat one extra meal (or snack) each day to add strength and health to their body. Mothers are encouraged to add up to nine kilograms each pregnancy.

If the mother is healthy, the infant will be healthy and strong too. This will help labor to go well. If the mother and infant are weak, labor may be difficult and they may have difficulty surviving the birth.

Pregnant and lactating mothers need to eat a variety of foods from different food groups each week.

These include meats and animal products (chicken, eggs, fish), plants (fruits and vegetables), and grains, staples and oils.

? Why do you think the father in this picture wants his wife to eat more?

Ruth’s husband knows that if his wife eats well, she will gain weight, and the infant will gain weight too. He wants his wife and his child to be strong for birth.

Our bodies are made of many different parts (like eyes, ears, tongue, skin, organs, blood, and saliva).

God has given us many different foods to keep each of our body parts strong.

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For example, eyes need certain nutrients that are different from the needs of the bones. Skin needs to be durable and soft, which is not the same as toenails and fingernails.

By eating a many different colors and types of foods, we can be certain that we give each part some of the nutrients that it needs.

Iron (Picture 3.3) - 5 minutes




Pregnant women should go to the clinic for a check-up as soon as they know they are pregnant. The health worker will let you know how often you should return.

The health worker gives pregnant women iron pills. Iron helps to make the woman’s blood strong. When iron is low,

women are tired and have less energy. Pregnant women should also add meat to their meals to increase

iron. Liver is the best food that a woman can eat to increase iron. Cooking in an iron pot is also helpful.

Mothers provide nutrients and blood to the infant to help it survive. Pregnant women will lose a lot of blood at birth, so women need to

make sure that their blood is strong before going into labor. If a mother has very weak blood and loses too much blood at birth,

she may not survive. Lactating mothers give a lot of nutrients in their breastmilk to

infants. The mother needs to have strong blood so that she can give the infant all of the nutrients it needs to grow.

Iodine (Picture 3.4) - 5 minutes

9. Show Ask the caregivers to describe what they see in the pictures on page 25.

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Pregnant and lactating mothers need more iodine than other women. Iodine is needed for the development of an infant’s brain. Children

whose mother’s included iodine in their meals will do well in school. If there is not enough iodine, children may be very slow (not very smart) and have trouble in school.

Mothers with low iodine may miscarry or have still births. When iodine is very low, women develop or lump on their neck, or

goiter. Even if a pregnant or lactating woman does not have goiter, she still needs to add more iodine to her diet.

Using iodized salt is a good source of iodine. Although it is a little more expensive, it can be used in small quantities and added to the family foods.

Mothers can also eat small pieces of salt water fish or other salt water animals.11

Iodized SaltShow Leader Mothers a bag of iodized salt. Show the Leader Mothers the label so they can find it in a store.

11. Activity: Checking Symptoms — 15 minutes

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

2. Ask the group: how many of you use iodized salt of salt water fish in your meals? Can you share with the others how you use it?

3. Ask them about the different foods that they eat each day. Do they eat grains, oils, meat products and plants each week? Ask mothers who eat a variety to share the foods that they make.

4. Use the positive examples to help others in the group to begin the new practices.

11 If you are not near an ocean or other salt waters, delete the reference above to salt water fish and animals.

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12. Probe — 10 minutes

? What do you think about these ideas? Do you think this advice would be difficult to follow? Is there anything that might stop you from following this guidance?


13. Inform — 5 minutes


Possible concerns:

? In summary, what would you suggest to Ruth to keep her strong during pregnancy and lactation?


She adds an extra meal or snack to her diet each day. She increases the different types and different colors of food that she eats. She cooks with salt that has iodine in it (she looks for the right label).

o She adds iodized salt to her diet. She visits a clinic for a checkup and gets a tablet for iron.

o She adds liver to her diet, or uses an iron cooking pot.



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Lesson 4: Anemia Prevention

Caregivers will be able to identify the symptoms of anemia. Pregnant women will sleep under a mosquito net each night to prevent

malaria. Pregnant mothers will seek treatment at the first signs of malaria. Pregnant mothers will increase their iron intake in the following ways:

o Add iron rich foods to their meals each week.o Avoid adding foods which block iron absorption such as tea, coffee,

cocoa, and sugary drinks to their meals. The caffeine in these drinks block iron absorption.

o Add foods containing vitamin C to meals with iron. These foods help to increase iron absorption. Vitamin C foods include citrus fruits (oranges, grapefruit, lemon, lime, and mandarin) as well papaya, sweet green and red peppers, potatoes and tomatoes.

Caregivers will believe: God has given us gifts (wisdom and local foods) to help us to be healthy.

Materials1. Attendance Registers

1. Game: Fruit Salad — 10 minutes

1. The Promoter divides the Leader Mothers into three to four groups. Each group is given a fruit name such as oranges, papaya and bananas.

2. Leader Mothers then sit in chairs (or on mats) in a circle. The Promoter stands in the center of the circle of chairs and should out the name of one of the fruits.

3. All of the women in this fruit group must change places with one another. The Promoter tries to take one of their places as they move, leaving another Leader Mother in the middle without a chair.

4. The new Leader Mother in the middle shouts another fruit name and the Leader Mothers in this fruit group must all change places with each other.

5. If someone says, ‘fruit salad’ all Leader Mothers have to change seats.

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

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Feeling Dizzy (Picture 4.1) - 5 minutes

3. Story: Read the story on page 24 of the flipchart

It has been two weeks since we last visited with Mary and Ruth. It is the morning, and time to work in the fields. Mary has eaten her porridge with milk, and was on her way to work, when she saw Ruth sitting on the ground. She stopped to find out what was wrong.

Ruth said that she had some tea (or other caffeinated drink) early in the morning. Then she was on her way to the field to begin working, but she had to stop and rest. Mary noticed that Ruth was breathing very fast, and it seemed she could not get her breath. Ruth said that she felt dizzy and was having fever.

? What things do you notice about Ruth?

She didn’t have a good breakfast. She is still feeling sick. She may have malaria.

She is having trouble breathing and has been feeling dizzy. She has trouble with her daily tasks and has to rest. The insides of her lip and tongue are very pale (show lack of blood).

4. Ask: Read the questions on page 26 of the flipchart. Encourage discussion. Don't correct "wrong answers." Let everyone give an

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


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After the participants answer the last question, move to the next flipchart page by saying, "Let's compare your ideas to the practices of Mary."

? What do you think is the cause of the illness?

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

Mary thinks that Ruth has low iron (a nutrient our bodies need). She examines her symptoms.

Ruth’s lips and tongue are very pale. The inside of her eyelids and fingernails are also very pale. These are signs of low iron.

Women with low iron are frequently tired, and lack energy. In severe cases, women with low levels of this nutrient have trouble catching her breath and the heart rate increases.

Mosquito Net (Picture 4.2) - 5 minutes




Mary explains that all pregnant and lactating mothers should sleep under a mosquito net each night. Mosquitoes are most active at dusk and dawn.

By sleeping under a net, mothers can prevent malaria which is spread by mosquitoes.

Malaria reduces the level of the nutrient iron in a woman’s body. This weakens her blood giving her less energy and strength.

When a woman is sick with malaria, it also prevents nutrients from getting to the infant.

Sleeping under a net each night will prevent malaria and help to maintain the levels of iron in pregnant and lactating women.

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Malaria Treatment (Picture 4.3) - 5 minutes




Mary tells Ruth that all pregnant women should go to the clinic to get tested for malaria at the first symptoms of malaria.

Signs of malaria may include headache, dizziness, and fever. She should take all of the necessary pills so that if she has malaria,

she can get rid of this illness immediately. Malaria reduces the level of the nutrient iron in the body. Iron is

needed for a healthy blood to support pregnancy, delivery and the infant’s needs.

Foods Rich with Iron (Picture 4.4) - 5 minutes




Pregnant women should eat foods with lots of iron. Beans, lentils, green leafy vegetables, and meat are all high in iron.

Try to add small amounts of these foods to your meals each day. Even if a mother takes an iron pill or uses an iron cooking pot, she

should continue to eat iron rich foods each day or as often as

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possible. When you eat foods high in iron, eat them with citrus fruits. Citrus

foods include lemon, oranges, limes, and grapefruit. Tomatoes, potatoes, papaya and red and green sweet peppers also increase iron absorption.

Pregnant women should not drink tea, cocoa, or coffee or other caffeinated drinks with meals. These drinks reduce iron absorption in the body.

If possible, avoid all caffeinated drinks while pregnant and lactating. If you feel that you must have these drinks, wait at least one hour before or after eating a meal before drinking.

11. Activity: Examining Eyes, lips and tongues — 15 minutes

1. Ask the women in the group to look at each other’s tongues, and insides of the lips and eyelids.

2. Find the women with the reddest tongue and insides of the lip and eyelid. Find the women with the palest tongues and insides of the lips and eyelids.

3. Ask them about the different foods that they eat each day. 4. Ask the group: What can we learn from the foods that are mentioned by the

women with the reddest tongues, or insides of the lips and eyelids? Are they eating certain foods that the others should try also?

5. Use the positive examples to give advice to those who seem to have less iron.

12. Probe – 10 minutes



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13. Inform – 5 minutes


Possible concerns: Please add possible concerns and solutions that might be common in your

area.










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16. Examine — 15 minutes

Ask each Leader Mother one-on-one about her commitments. ? What was your commitment at the last lesson? Have you kept that commitment? How - what did you do?

Finally, ask each Leader Mother one-on-one about her practices in the last two weeks:o Have they tried to add more foods to their diet (pregnant and lactating

women)?o Have they tried to use foods of many different colors to their diet?o Are they using iodized salt?o (For those who are pregnant), have they visited the clinic for an iron pill?

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Lesson 5: Early Initiation of Breastfeeding

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

o Putting the newborn to the mother’s chest helps form a bond between mother and infant.

o The infant stays warm when laid skin-to-skin on the mother’s chest.o Interacting with the newborn infant helps the mother’s breasts to

develop milk more quickly. Mothers will begin breastfeeding within one hour after birth so that infants

receive the first milk (colostrum). o Colostrum protects the infant from illness. o Colostrum helps to clean the infant’s stomach (to expel the first

dark stool).o Colostrum is the perfect mix of nutrients designed specifically for

newborn infants. o The infant’s sucking on the breast after birth stimulates the

mother’s breast to begin producing more milk.o Putting a newborn infant to the breast teaches the infant how to

suck. Mothers will be able to demonstrate good breastfeeding position and

attachment. Caregivers will believe: God has given us gifts (the ability to provide) to bring

life and health to our children.

Materials1. Attendance Registers 2. Blindfolds (or scraps of fabric)

1. Game: Blindfold Pairs – 10 minutes

1. An obstacle course is set out on the floor for everyone to look at (place chairs, or mats, or other people in the path to the other side). An ending line or “target” is identified on the opposite side of the room.

2. Participants split into pairs. One of the pair puts a scarf around their eyes, or closes their eyes tightly so they cannot see.

3. The other member of the pair now gives advice and direction to their partner to help them to get safely to the other side of the room.

? What helped you to get to the other side? If you tried to cross the room without any help, would it be difficult for you?

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? What can we learn from this game?

As we teach, we need to guide those who are “lost” or “blindfolded.” We need to encourage others and support them, (not force them) to go

certain direction (or follow a new practice).

Now that we are finished with our game, let’s begin.







Breast or Bottle (Picture 5.1) - 5 minutes

3. Story:

Read the story on page 32 of the flipchart.

? What did you notice about the birth? What choices did they make about feeding and caring for the newborn?


4. Ask13 The Activity Leader should arrive ten minutes prior to each care group meeting to get the description of the activity and the list of needed items from the promoter.

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Ruth gave birth today to a boy. The birth was long and difficult. Ruth has named him Hardship. After the baby’s cord was cut and he was cleaned, they wrapped him in a blanket and took him into another room to feed. Ruth’s mother reminded Ruth her that she had been sick during her pregnancy and this had made her milk sour. “We must use a bottle him.” her mother-in law said. Ruth continued to lose blood.

Read the questions on page 34 of the flipchart. Encourage discussion. Don't correct "wrong answers." Let everyone give an

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

page by saying, "Let’s compare what your practices with Mary. She also gave birth this morning to a girl child. Her name is Of Great Worth.

? What did you feed your infant at birth?? What is the best practice for the care of an infant in the

first few hours of life?

Immediate breastfeeding (Picture 5. 2) - 5 minutes




After cutting the umbilical cord and cleaning the infant, birth attendants should place the infant onto the mother’s chest.

This helps to form a bond between mother and child and keeps the infant warm.

Within the first hour after birth, mothers should put the infant to the breast to begin breastfeeding.

The first yellow milk contains germ fighting agents so the infant will be protected against illness. It is like a natural vaccine to fight infant illness.

The first yellow milk also cleans the baby’s stomach (like the mother’s natural butter) helping to expel the baby’s first dark stool.

Breastfeeding helps the mother’s muscles to contract (or shrink) and stop bleeding after delivery.

When the infant takes the first milk, it helps the mother’s white milk to come in sooner.

? What are some of the advantages of breastfeeding?

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Encourage discussion. All women HAVE breasts; they don’t need to be purchased. All women’s breasts COME with breast milk; the food does need to be

prepared and is the perfect temperature. Women’s breast milk multiplies based on the infants’ need. If an infant sucks

many times a day, the breasts will make more milk for the infant. God designed women’s breasts so that they can produce different kinds of

milk at different times. The milk changes as the needs of the infant and child change during the first two or more years of life.

Breast is Best (Picture 5.3) - 5 minutes




Just like we guided our friends in the blindfold game, an infant needs to be helped to have the correct position on the breast.

The infant must have his mouth open wide, with his lips curled back, and his chin against her breast.

If he is only sucking on the teat, it is a poor position. He will not get enough milk and the mother’s breasts will become sore.

The mother should be comfortable. The infant can lie beside her or across her front or under her arm. Just as long as the infant faces the breast and can take enough of the breast into his mouth from the position.

Food and water will make infants sick if it is given to them before they are six months or age. Breastmilk is the only thing an infant needs.

Infants should not be given water, or any other food or drink for the first six months of life.

9. Activity: Good Attachment – 15 minutes

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1. Ask mothers with infants under six months of age to demonstrate the different ways they breastfeed their child.

2. Others in the group should gather around and see if there is good attachment.

3. Ask, “What other positions can you use for breastfeeding?” 4. Encourage those who have good attachment.

10. Probe 10 minutes



11. Inform 5 minutes







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16. Examine – 5 minutes


Finally, ask each Leader Mother one-on-one about her practices in the last two weeks:o Are they using a mosquito net (pregnant and lactating women only)?o Have they tried to add citrus fruits and tomatoes to meals with iron? o Have they decreased or stopped drinking coffee or tea with foods high in iron

(pregnant and lactating women only)?

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Lesson 6: Exclusive Breastfeeding

Mothers will exclusively breastfeed their infants from birth to six months of age.

o No other foods or drinks, not even water will be given to the infant.o Mothers will continue breastfeeding for at least twenty four months

or more. Mothers will breastfeed in the following ways:

o Breastfeed whenever the infant cries or shows that he is hungry - day and night.

o Mothers will offer both breasts: emptying one breast and then switching to the other breast.

o Mothers will breastfeed even when they are feeling sick. Mothers will eat well to increase their milk production.

o Mothers will drink a lot of fluids when they are breastfeeding.o Eat a variety of foods of many different colors.o Lactating mothers will eat an extra portion of food each day.

Mothers will avoid things that reduce their milk production. o Do not give other foods or liquids to infants under six months. The

infant will suck less on the breast and the breast will produce less milk.

o Mothers will be confident that they have enough milk. Worry and anxiety may decrease milk production

Caregivers will be able to name the people in their lives who would support and encourage them with exclusive breastfeeding (increased perceived social acceptability).

Caregivers will believe: God has given us gifts (the ability to provide) to bring life and health to our children.

Materials1. Attendance Registers

1. Game: Who is the Leader — 10 minutes

1. Ask the Leader Mothers to sit in a circle. A volunteer leaves the room. 2. After they leave, the rest of the group chooses a leader. The leader must

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

3. The volunteer returns and stands in the middle of the circle. At this time the leader of the group should begin an action just as she had done a few

45

minutes ago. The others follow the leader doing the action with her. After a few seconds she changes the action. As soon as the others see, they should do the same action that the leader is doing.

4. The volunteer tries to guess who is leading the actions. The leader must change the actions without getting caught. The group protects the leader by not looking at her.

5. When the volunteer spots the leader, the volunteer joins the circle, and the person who was the leader leaves the room.

6. Repeat the game several times.

? What can we learn from this game?

Sometimes the person who is making decisions is hidden. Often when we meet with women, there are others in the room (or in their

life) that lead or influence their decisions. We need to find the people who make decisions in the household and find

creative ways to persuade them to practice good health practices.

Let’s begin the lesson with a review of the last two weeks.

2. Attendance and Troubleshooting – 15 minutes




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

11.Promoter asks the group’s Activity Leader14 to discuss the needed items for next week’s activity and solicit volunteers.

Family Pressure (Picture 6.1) - 5 minutes

3. Story: Read the story on page 40 of the flipchart.

Ruth’s infant Hardship is small, but is growing a little. Ruth still feeds him with a bottle and milk powder that she buys at the market. But the milk powder is expensive, so sometimes she is not able to mix all of the


46

suggested powder into the bottle. She would like to try to breastfeed again, but her breasts are empty. She also knows that her mother-in-law would not allow her to breastfeed. Her mother-in-law believes that Ruth’s breast milk is bad. Ruth decides to go talk with Mary. Mary is always kind and helpful. She hopes that Mary might be able to give her some advice. 15

4. Ask: Read the questions on page 40 of the flipchart. Some answers to the third question are the following: She could ask Mary to talk with her mother-in-law. Ruth could ask her husband to talk with his mother. Mary could bring her mother-in-law over to Ruth’s house and let her ask Mary

questions. Mary could ask other elder women who support breastfeeding to talk with her

mother-in-law. After the participants answer the last question, move to the next flipchart

page by saying, "Let's compare your ideas to the practices of Mary."

? Why do you think Ruth’s infant is small and weak?? Is milk powder as nutritious as breast milk?? What are some ways that Ruth can talk with her mother-in-

law to overcome the problems at home?

Let’s continue our story. Ruth goes to Mary’s house. She knows that Mary encourages everyone to breastfeed. She asks for her help.

Exclusive Breastfeeding (Picture 6.2) - 5 minutes



15This story emphasizes the low social acceptability of breastfeeding in Ruth’s family. Perceived social acceptability is a behavior determinant found in Barrier Analysis. Ruth is discouraged because her mother-in-law does not want her to breastfeed. Use this story and discussion to talk about what is socially acceptable for mothers. Emphasize the people who WOULD support them exclusively breastfeeding. Help teach them ways to discuss new practices with family members who disagree.

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Mary has convinced Ruth that if she wants [Hardship] to survive she must give breastfeed him.

Bottle fed infants often get sick because the powder does not contain the nutrients that the infant needs.

Bottles and water also carry germs that make infants sick. Breast milk is the perfect mix of nutrients for an infant and will help

an infant to remain healthy. Mothers should give only breastfeed for the first six months of life.

Even if you did not breastfeed at birth. It is not too late to start. Let your infant suck whenever the infant is interested. Offer your breast to him all through the day.

The more you sit with him, and give him your breast, the quicker that your new milk will come.

Your breast milk will not go sour or bad. It is always healthy for the infant. Breastfeed even if you are sick. If the infant is sick, give him your breast more often to help him recover.

God has designed women’s breast to provide milk that is always nutritious and healthy for infants and children. Even if the mother is malnourished or sick, her breast milk is still the best food for infants and children.

Only those with HIV should talk with a health provider to see if there are other options for their infant.16

Timing (Picture 6.3) - 5 minutes




Mothers should breastfeed from both breasts. Starting on one breast, until the infant releases. Then switching to the other breast until the infant is finished.

Breastfeed from each breast at every feeding. Breastfeed whenever the child cries, begins sucking their fingers or

16 Mother to Child transmission of HIV will be covered in Module 6.

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hands, or shows that they are hungry. Breastfeed at least ten times a day (24 hour period) day and night to

satisfy the infant’s hunger and help the infant to grow strong. Breast milk is the only food and liquid that an infant from birth to six

months of age needs.

Getting a Vitamin A Capsule (Picture 6.4) - 5 minutes




Six weeks after giving birth,17 mothers should to the clinic for a vitamin A capsule.

Vitamin A helps protect the mother from infection and keeps your eyes strong. Some of the mother’s vitamin A is shared with her child through breast milk. Vitamin A also protects the baby’s eyes and helps them to grow well.

Because the mother and infant are sharing vitamin A, breastfeeding women need to make sure that they get a vitamin A capsule from the health worker.

The health worker can also help mothers to increase their milk production.

o Mothers should drink a lot of fluids when they are breastfeeding.

o Eat a variety of foods and eat an extra portion of food each day.

o Try to be relaxed. Be confident that you can provide for your child. God has designed it this way.

o Do not give other foods or liquids to infants under six months. The infant will suck less on the breast and the breast will produce less milk.

? Based on this guidance, what should Ruth do now?

17 Recommendation is six weeks for non-breastfeed infants and eight weeks for exclusively breastfed infants. We are using six weeks as a general recommendation.

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She should start breastfeeding again, reducing the other foods each day until the infant is exclusively breastfeeding.

She should feed the infant on demand using both breasts. She should continue to eat a variety of foods with many colors. She should drink more fluids and breastfeed even if she is ill. She should talk with her mother-in-law and find ways that they can

agree on a healthy guidance.

11. Activity: Breastfeeding Problems — 15 Minutes

1. Ask mothers about problems that they have had breastfeed (problems may include inverted nipples, sore nipples, and poor milk production).

2. Ask other mothers if they have had these problems. Try to find solutions and help mothers to overcome problems that they are having.

3. Encourage mothers to pair up with a mother who has more experience to find solutions and help encourage each other.

12. Probe —10 minutes



13. Inform — 5 minutes


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Possible concerns:

Please add possible concerns and solutions that might be common in your area.











16. Examine — 15 minutes

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Finally, ask each Leader Mother one-on-one about her practices in the last two weeks:

o (If they gave birth in the last two weeks) did they put the infant immediately to the breast?

o (If they have a child less than six months) are they breastfeeding exclusively? o (If they have a breastfeeding child) ask them to show you the correct

attachment.

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Lesson 7: Meeting with other Caregivers: encouraging breastfeeding practices.18

Caregivers will be able to explain why breast milk is the only food and liquid needed for infants from birth to six months.

Caregivers will encourage mothers to continue breastfeeding until at least 24 months of age or more.

Caregivers will encourage the mother to breastfeed and eat an extra portion of food each day.

Caregivers will discuss obstacles (beliefs, customs, and practices) to healthy feeding and ways to overcome them.

Caregivers will talk with mothers about their needs and how they can help. Caregivers will believe: God has given women a gift (the ability to provide

breast milk) to bring life and health to our children.

Materials1. none

1. Game: The Knot — 10 minutes

1. Ask the Leader Mothers to stand in a circle, with shoulders touching. 2. Each Leader Mother should grab the hand of another Leader Mother. 3. They should not be holding the hand of the person next to them on either

side.4. They must use both hands, but CANNOT hold two hands of the SAME person.

Each Leader Mother should be holding hands with two different people. 5. Then, ask the Leader Mothers to untie the “knot.” 6. They cannot let go of hands. They can lift arms over shoulders, and step over

clasped hands. Encourage them to work together to untangle. 7. They should finish with one single circle (some may be facing out rather than

in).

? What can we learn from this game? We need each other to solve problems. We need everyone to agree and help each other. Sometimes even mothers and husbands can’t solve problems on their own.

We may also need grandmothers and mother-in-laws and health workers.

18 The lesson was designed to help other family caregivers such as grandmothers, mother-in-laws and husbands to support and encourage exclusive breastfeeding.

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

2. Attendance and Troubleshooting ─ 15 minutes






Our Community (Picture 7.1) - 5 minutes



Encourage discussion This program is your program. With your experience, talents, and time we

can work together to bring improved health in your community. The program focuses on improving the nutrition of pregnant and lactating

mothers and the nutrition of their children. It gives mothers, pregnant women, and other caregivers information to stay healthy and well nourished.

When mothers are healthy, their children are more likely to be healthy too. The training not only teaches mothers how to be strong during and after

pregnancy, but gives information about caring and supporting their children for the first two years of life. This support helps them to survive and grow.

Mother cannot do this alone. We need your help too.

In today’s meeting we want to discuss breastfeeding practices.


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4. Ask: Read the questions on page 6 of the flipchart. Encourage discussion. Don't correct "wrong answers." Let everyone give an

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

page by saying, "Let's compare your ideas to the practices of Mary."

? From your experience, what is the importance of giving breast milk to infants

? How often should a mother breastfeed? Does an infant need other food and drink to grow strong

in the first six months of life

? From your experience, what is the importance of giving breast milk to infants? How often should a mother breastfeed? Does an infant need other food and drink to grow strong in the first six months of life?

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

Let’s compare your practices with those of Mary from our lessons.

Immediate breastfeeding (Picture 7.2) - 5 minutes

5. Show:

Ask the caregivers to describe what they see in the pictures on page 37.



After cutting the umbilical cord and cleaning the infant, birth attendants should place the infant onto the mother’s chest.

This helps to form a bond between mother and child and keeps the infant warm.

Within the first hour after birth, mothers should put the infant to the breast to begin breastfeeding.

The first yellow milk contains germ fighting agents so the infant will be protected against illness. It is like a natural vaccine to fight infant illness.

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The first yellow milk also cleans the baby’s stomach (like the mother’s natural butter) helping to expel the baby’s first dark stool.

Breastfeeding helps the mother’s muscles to contract (or shrink) and stop bleeding after delivery.

When the infant takes the first milk, it helps the mother’s white milk to come in sooner.

? What are some of the advantages of breastfeeding?

Encourage discussion. All women HAVE breasts; they don’t need to be purchased. All women’s breasts COME with breast milk; the food does need to be

prepared and is the perfect temperature. Women’s breast milk multiplies based on the infants’ need. If an infant sucks

many times a day, the breasts will make more milk for the infant. God designed women’s breasts so that they can produce different kinds of

milk at different times. The milk changes as the needs of the infant and child change during the first two or more years of life.

Breast is Best (Picture 7.3) - 5 minutes

7. Show Ask the caregivers to describe what they see in the pictures on page 39.



This woman had two children. When her first child was born (the top picture) her friends and family

encouraged her to breastfeed. They encouraged her to start giving him breastmilk as soon as he was born and to give only breastmilk—no other foods or drinks—for the first six months of his life. You see her breastfeeding him here.

Here she is with her second child (the bottom picture). Her mother-in-law was concerned that she might not have enough

milk to feed this child and told her not to give breast milk to this infant. Instead she encouraged her to feed formula to the infant and give other things to drink.

Although this second child was the same age as the first child in this

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picture, notice how much smaller this infant is. The day after the picture was made, this infant died.

The mother asked that these pictures be used to encourage mothers all over the world to start breastfeeding immediately after the baby’s birth and to give only breast milk for the first six months.20

Food and water will make infants sick if it is given to them before they are six months. Breast milk is the only food that will make them healthy and strong.

Helping Mothers (Picture 7.4) - 5 minutes




Mothers need more food when they are pregnant or lactating. We can make sure they have extra food at each meal. They need to eat enough for themselves and their infant. Encourage them to eat more than usual.

Give encouragement and emotional support when a mother is having a hard time breastfeeding. It may be difficult and sometimes uncomfortable for the mother.

Be helpful to the mother whenever possible, allowing her time to breastfeed without interruptions.

Take time to interact with the infant; giving the mother a break when she is not breastfeeding.

Ask the mother if there are things that you can do to help.

11. Activity: Role Play ─ 15 minutes

1. Ask Leader Mothers to role play with another woman in the group.2. One woman should pretend to be a mother breastfeeding. The other woman

will pretend to be a husband, mother-in-law or grandmother. The husband, 2019 Adapted from Improving Breastfeeding—Everyone Can Help Copyright © 2003, 1999 Freedom from Hunger

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mother-in-law or grandmother should practice doing the new things that they learned today.

3. They can practice offering help. They can practice playing alone with the infant of child. They should role play giving extra food to their spouse, etc.

4. After five to ten minutes, ask the women to switch roles. The other woman should now pretend to be a husband or mother-in-law etc.

5. Encourage the Leader Mothers to find NEW ways that they can help each other.

6. The Promoter should watch, correct, and help the Leader Mothers who are having trouble with the role play.

7. When everyone is finished ask them to share the things that they learned. 8. What other ways can family members help mothers? 9. Leader Mothers should use this same exercise with caregivers who come to

their meetings with neighbors.

12. Probe ─ 10 minutes

? What do you think about these ideas? Do you think this advice would be difficult to follow in your home? Is there anything that might stop you from following this advice?


13. Inform ─ 5 minutes




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