Peace Corps Guide for Pregnant Women’s support group program__Final Draft August 2008
Acknowledgements
The Foyer d’Apprentissage et de Renforcement Nutritionnelle des Femmes en Grossesses (FARN/G) (also known as the pregnant women’s support group) approach was created in Guinea in 2001. The approach was developed by staff from Helen Keller International (HKI),Guinea under a subgrant from USAID/Food for Peace, in collaboration with Africare-Guinea and the Ministry of Health in Dinguiraye, Guinea. The approach was adapted from the Positive Deviant (PD)/Hearth Nutrition (for malnourished children) model, which is based on identifying local women in communities who use positive nutritional practices to feed their children. The PD/Hearth model is used to teach mothers how to rehabilitate moderately malnourished children. In the FARN/G approach, positive deviant role models are identified to improve the nutritional practices of pregnant women, to promote information sharing and sharing experiences on safe motherhood practices, and community cohesion. The FARN/G approach was originally pilot tested in Guinea, and has been modified and expanded in Sierra Leone. Although the PD/Hearth nutrition approach and the FARN/G approach share a similar philosophical basis (the idea that you can identify resident role models within a community to teach others how to improve practices using local resources), the objectives and components of a FARN/G program and the way such a program is implemented are fundamentally different from a PD Hearth program. Hopefully this manual will explain those differences, as well as illuminate some of the benefits and difficulties inherent in the approach, and lessons learned during program implementation in Guinea and Sierra Leone.
This manual was drafted by Cathleen Prata (Peace Corps Guinea 2006 and 2008, Mali 2007). It is an adaptation of the FARN/G manual used by HKI/Guinea, and incorporates elements from PD Hearth manuals used in Guinea and Mali. There are many people who helped in the creation of this manual and deserve recognition.
Thanks are due to HKI staff members Dr. Lanfia Toure, Dr. Appolinaire Delamou, Dr. Midiaou Bah and Aliou Bah who work closely with communities and Ministry of Health teams throughout Guinea, and whose experiences, hard work and dedication resulted in the current success of the FARN/G program. A special thanks to Dr. Lanfia, who provided technical assistance for the development of this manual.
Thank you to Jennifer Peterson (HKI/Guinea and Sierra Leone), who not only shared many HKI documents to create this manual, but also her support and expertise.
Thank you to Dr. Mohamed Lamine Keita, Dr. Fodé Konaté, Lynn Morin and Aurélien Barriquault for their studies on the FARN/G approach. Their work provided insights for the creation of this manual.
As this manual was requested by Agnieszka Sykes (Community Health Specialist, Peace Corps, Washington DC), it is necessary to acknowledge not only her pushing for such a manual to exist, but her enthusiasm for the project, as well as her input and editing.
Since this manual uses many concepts from the Mali Hearth manual, it is necessary to thank Ariel Wagner, who created the Mali Hearth Manual and provided input for this manual (Peace Corps Mali 2005-2008).
It is also necessary to thank Annaliese Limb (APCD Peace Corps, Guinea 2005-2008) for her editing and suggestions.
Special thanks to Ryan Derni (Peace Corps Guinea, 2005-2007), who facilitated the preparatory steps for a FARN/G program and was able to share his experiences with us.
It is also necessary to thank the CORE group, who continues to revamp, based on experiences from all over the world, the CORE PD/Hearth manual.
Finally, a huge thank you to all of the extraordinary mothers, fathers, district health staff and community health volunteers that have made FARN/G a successful program in Guinea.
Acronymes
FAF Fer Acide Folique (Iron/Folic Acid supplement)
FARN/G Foyer d’Apprentissage et de Renforcement Nutritionnelle pour Gestantes
FGD Focus Group Discussion
GF Guinean Franc
HKI Helen Keller International
NGO Non-governmental Organization
PD/HEARTH Positive Deviant/Hearth
PNC Prenatal Consultation
TBA Traditional Birth Attendant
UNICEF United National Children’s Fund
VAD Vitamin A Deficiency
WHO World Health Organization
TABLE OF CONTENTS
Acknowledgements
Acronyms
Pregnant Women’s Support Groups (FARN/G)
I. INTRODUCTION
1. Maternal and Childhood Malnutrition
2. BACKGROUND
3. OBJECTIVES
4. PROGRAM IMPACTS
5. FARN/G AND VOLUNTEER SERVICE
II. STRATEGY
1. KEY PLAYERS
2. IMPLEMENTING A PREGNANT WOMEN’S SUPPORT GROUP PROGRAM
2.1 Communicate with Local Health Officials
2.2 Mobilize Communities
2.3 Train TBA's, Health Center Staff and Village Health Committee
Conduct a village census of pregnant women
2.5 Identify and Train Model Mother
2.6 Prepare Monthly Support Group Logistics
2.7 Conduct Monthly Support Group Sessions
2.8 Monitoring and Evaluation
III. FUNDING
IV. TROUBLESHOOTING
V. CONCLUSION
APPENDICES
Appendix A
Appendix B
Appendix C
Appendix D
Appendix E
3. List of those present during FARN/G
Appendix F
Appendix G
Sources
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Peace Corps Guide for Pregnant Women’s support group program__Final Draft August 2008
Pregnant Women’s Support Groups (FARN/G)
▪ Some 1,400 women die every day from problems related to pregnancy and childbirth.▪The dangers of childbearing can be greatly reduced if a woman is healthy and well nourished before becoming pregnant.
I. INTRODUCTION
Pregnancy and Safe motherhood
Many women in developing countries risk death and disability every time they become pregnant. Complications before, during, and after childbirth can often be fatal in the developing world. Some 1,400 women die every day from problems related to pregnancy and childbirth. Tens of thousands more experience complications during pregnancy, many of which are life-threatening for the women and their children – or leave them with severe disabilities. The vast majority of these deaths could have been prevented through good quality care during pregnancy, delivery, and the postpartum period.
The dangers of childbearing can be greatly reduced if a woman is healthy and well nourished before becoming pregnant, if she has a health check-up by a trained health worker at least four times during every pregnancy, and if the birth is assisted by a skilled birth attendant such as a doctor, nurse or midwife (UNICEF; Facts for Life on Safe Motherhood
Maternal and Childhood Malnutrition
Maternal and child malnutrition remain key public health challenges that merit particular attention in the context of safe motherhood. The principal nutritional challenges are insufficient energy and protein
▪ Maternal and child under nutrition is the underlying cause of 5 million deaths and 35% of the disease burden in children younger than 5 years[i]▪Poor fetal growth or stunting in the first 2 years of life leads to irreversible damage, including shorter adult height, lower attained schooling, reduced adult income, and low birth weight1
consumption, iodine deficiencies, anemia due to iron deficiency and vitamin A deficiency. Although the consequences of malnutrition can be serious, it is often an invisible problem. In general, there are no exterior signs, and those malnourished themselves are not aware of the problem.
Between 5 to 20 percent of women in various African countries are underweight. Low weight for height, low pregnancy weight gain, and low birth weight reflect inadequate food intake in women. Maternal malnutrition can lead to low birth weights for infants, as well as micronutrient deficiencies.
Many of the health risks associated with maternal malnutrition are the following:
Health risks associated with poor maternal nutrition[ii]For Maternal Health / For Infant Health
• Increased risk of maternal death / Increased risk of fetal and neonatal death
• Increased infections / • Intrauterine growth retardation
• Anemia / • Low birth weight
• Compromised Immune Systems / • Compromised Immune Systems
• Lethargy and weakness / • Premature birth
• Lower productivity / • Birth defects
• Cretinism[1] and reduced IQ
Many women display not one but several micronutrient deficiencies. Improving micronutrient status through diet diversification and micronutrient supplementation is an important step to reducing maternal malnutrition and consequently reducing rates of maternal morbidity and mortality. Minimal intake of micronutrient-rich foods and the body’s inability to absorb and efficiently use certain micronutrients both account for the prevalence of multiple deficiencies. Multiple deficiencies in zinc, iron, iodine, vitamin A, folic acid, vitamin B6, vitamin B12, vitamin D, calcium, and magnesium can increase the risk of low birth weight, preterm births, premature rupture of membranes, and fetal death. See Appendix B for Micronutrient Information.
2. BACKGROUND
In an effort to address high rates of both maternal, neonatal, and infant morbidity and mortality, the Community-based Pregnancy Surveillance Program (FARN/G or Le Foyer d’Apprentissage et de Renforcement Nutritionnel pour Gestantes) was inspired by the Positive Deviant Hearth Nutrition Model (originally designed for malnourished children). The original concept of the Positive Deviance (PD) / Hearth Nutrition Model was introduced in the 1980s in Haiti and has since been replicated in countries as various as Vietnam, Bangladesh, Mozambique and Guinea. In contrast to traditional nutrition interventions which tend to look for problems in the community that need to be solved, the Positive Deviant approach looks for positive behaviors and strengths that exist in the community and can be built upon. It is based on the belief that despite poverty, there are local practices, knowledge, and resources that can be exploited to promote positive health practices.[iii] The FARN/G approach utilizes a woman who has successfully given birth to healthy children as a positive deviant model and trainer for women who are currently pregnant, while also providing women with proper prenatal care (vaccinations, medication, vitamin/micronutrient supplements and referrals when necessary). It is an approach designed to improve the nutritional status of mothers and children by changing mothers’ attitudes and practices. The approach uses social support, self-efficacy and culturally acceptable and financially feasible alternatives to sustain behavior change.
In the FARN/G approach, the community is ultimately responsible for the care of these pregnant mothers. The program involves district level health officials, community leaders, traditional birth attendants, community health committees, community health volunteers, and pregnant women and their husbands in its preparation and its implementation. By involving community leaders and heads of households, including husbands and mothers-in-law, the program builds local support for pregnant women. Once the program is implemented, a Pregnant Women’s Support group meets once a month.
3. OBJECTIVES
The goal of the FARN/G program is to reduce maternal and infant mortality by decreasing infant and maternal malnutrition. The objectives of the program are to reduce anemia through improved nutrition practices, deworming, malaria treatment and Iron/Folic Acid supplementation; to improve vitamin A status through improved nutrition practices and post partum vitamin A supplementation; and to improve prenatal care coverage, especially in the 9th month of pregnancy. The program seeks to attain these objectives by implementing the following strategies during women’s monthly support group meetings and home visits:
1) Assure each pregnant mother has at least 3 prenatal consultations, including one in the 9th month, through prenatal care outreach sessions;
2) Facilitate Iron/Folic Acid supplementation and administration of anti-malarials, deworming medication and post partum vitamin A supplementation during prenatal care outreach;
3) Inform pregnant women of pregnancy danger signs for referral to health centers or hospitals, and help women, their families and communities prepare for safe delivery;
4) Sensitize women on good food and hygiene practices, immediate and exclusive breastfeeding and the importance of getting rest to increase the chances of a healthy pregnancy and delivery;
5) Bring pregnant women together to share their experiences and problems related to pregnancy, and encourage community support for and care of pregnant women;
6) Facilitate and encourage contact and communication between health center staff, traditional birth attendants, and pregnant women and their husbands to promote positive pregnancy practices, and to encourage increased demand for health care services.
4. PROGRAM IMPACTS[iv]
In 2007, Guinea’s Ministry of Health in conjunction with HKI conducted a study on the impacts and effects of the FARN/G approach. The study is based on interviews with 400 participants and 202 non-participants. Dr. Mohmed Lamine Kieta analyzed the results. He found that women were more knowledgeable about proper pre and post natal care and as a result experienced healthier and safer pregnancies than those who did not participate. Women who participated in the program were more likely to have received tetanus vaccination, Iron/Folic Acid supplements, deworming medication and treatment for malaria during pregnancy than those who did not participate. 86% of the women participating in FARN/G received a post partum Vitamin A supplement as opposed to 51% for those who did not participate.
The study shows that those who participated in the program benefited from the nutritional messages given during FARN/G sessions. The program teaches that the first hour after birth is a critical time as the first milk or colostrum is high in vitamin A and serves as the child’s first immunization. Children born to mothers who participated in the program (71%) were more likely to be breastfed within the first hour after birth than those children whose mothers did not participate (50.7%). 80% of children born to participants were breastfed exclusively, while the rate was only 59% for non-participants. In addition, participants were more likely to be able to identify signs of anemia, Vitamin A deficiency and iodine deficiency than non participants. They were also more able to name foods rich in iron, Vitamin A and iodine.
The study collected information on the nutritional status of the women and the children they gave birth to between 2003 and 2006. The study found that women participating in the program were less likely to suffer from anemia (27.7%), whereas the rate of anemia among non-participant was 43.8%. Recovery time for women who participated in the program was about 4 days, as opposed to 8 days for those not participating. Children born to women who participated were less likely to suffer from malnutrition than those who did not participate. Anemia and morbidity rates among children, as well as rates of children suffering from illness were all almost 10% higher for those who did not participate in the program.
5. FARN/G AND VOLUNTEER SERVICE
FARN/G can help give a volunteer’s service direction. The first three months of service are generally spent focused on language, learning the dynamics of your community, and building relationships. FARN/G can help you in this process. Your involvement in this program will help you understand local cultural practices that have direct impacts on child health, identify valuable work counterparts, and help you demonstrate your professional skills. As soon as you feel comfortable, you can begin by organizing small focus group meetings to discuss pregnancy practices, leading up to the implementation of a full FARN/G program. Pregnancy is something that everyone cares about, and which affects everyone’s life. Using the results of your focus group discussions, you can identify the most important components of a positive pregnancy program in your community, and map out a communication strategy to support it. After you organize a FARN/G group in your community, you can conduct FARN/G trainings with local community health volunteers or health agents in order to expand the program and establish it in areas where Peace Corps Volunteers are not currently working. Regardless of how you choose to integrate FARN/G into your service, the approach is an excellent way to increase people’s confidence in you and your visibility in the community regardless of your assigned Peace Corps sector.
FARN/G groups can also lead to secondary projects, such as kitchen gardens or gardening for nutrition, building mud stoves, income-generating activities with women’s groups, discussions of women’s and children’s rights, and special FARN/G groups for families living with HIV/AIDS. Not only will new ideas come up, but FARN/G also provides you with potential counterparts. You will be able to continue working with community health volunteers and FARN/G participants to spread health and nutrition messages to other audiences.
II. STRATEGY
This section outlines the key players, steps for implementing a Pregnant Women’s Support Group program, the main activities that take place during a monthly support group meeting and the follow-up of women post delivery. See Appendix A for a simple formula of elements to keep in mind when conducting a FARN/G program.
1.KEY PLAYERS
RoleDistrict level health officials / To supervise the implementation of the FARN/G program on at least a quarterly basis, and to provide constructive feedback to health center staff and community health committees. To collect, summarize and analyze FARN/G data and send it to the regional level.
HealthCenter staff member (usually a vaccination agent) / To train the village health committee, community health volunteer, the TBA's and the model mothers regarding their roles and responsibilities in the FARN/G program, and to provide regular (monthly) outreach visits to FARN/G communities. To help FARN/G sites overcome supply constraints through improved planning and management. To encourage women in their ninth month to deliver their babies at the health center, with a trained midwife. To promote immediate and exclusive breastfeeding.
Traditional Birth Attendant / To take pregnant women to health centers for their first prenatal exam, to stay with women during delivery, to facilitate post partum VA distribution, and to take newborn babies to health centers to be weighed and documented. Share nutritional advice, mobilize women for FARN/G events, and conduct household visits to FARN/G participants.
Village Health Volunteers / To conduct a census of all the pregnant women in the area, share nutritional advice, mobilize women for FARN/G events, conduct household visits to FARN/G participants, and weigh the participants.
Village elders, traditional and religious leaders / To mobilize or encourage pregnant women and their husbands to participate in the FARN/G program. To oversee the implementation of the program, and report any problems to health center staff or the DPS. To facilitate the identification of a location for the women to meet.
Model Mother (positive deviant mother) / To encourage women to participate in the FARN/G program, share nutritional recipes and pregnancy tips with participants, and to cook nutritious meals for FARN/G participants.
Pregnant women / To attend at least three FARN/G sessions; to apply lessons learned during these sessions (be willing to give them a try); to take the medications which are distributed; and to discuss openly their problems related to child birth and pregnancy, and try to solve them. To contribute financially to the FARN/G program (for lunch), and to prenatal care costs.
Husbands of pregnant women / To accompany their wife to prenatal consultations, support increased consumption of micronutrient rich foods during pregnancy, help their wives locate the resources they need to participate in the FARN/G and to purchase their prenatal consultation cards, and to encourage them to take it easy, get rest, and take their medications
2.IMPLEMENTING A PREGNANT WOMEN’S SUPPORT GROUP PROGRAM