Factors That Can Influence The Counselling Session - Counselling For Maternal and Newborn Health Care - Ncbi Bookshelf

3/23/2017 FACTORSTHATCANINFLUENCETHECOUNSELLINGSESSIONCounsellingforMaternalandNewbornHealthCareNCBIBookshelf
NCBIBookshelf.AserviceoftheNationalLibraryofMedicine,NationalInstitutesofHealth.
CounsellingforMaternalandNewbornHealthCare:AHandbookforBuildingSkills.Geneva:WorldHealth
Organization2013.
4 FACTORSTHATCANINFLUENCETHECOUNSELLING
SESSION
Whatisinthissession?
Thissessionfocusesonsomeofthedifferentfactorsthatcanaffectorinfluencecounsellingfor
MNH.Theseincludethelargersocialandculturalcontext,includingsocioeconomicconditions,
culturalandsocialnorms,genderroles,andhouseholddecisionmakingprocesses.
Thesediversefactorswillimpactuponyourcounsellingsessionthereforeadeeperunderstanding
oftheirinfluenceisrequired.Thissessionalsoconsidersspecificsituationssuchascouple
counselling,andcounsellingonsensitiveissuessuchassexuality.
WhatamIgoingtolearn?
Bytheendofthissessionyoushouldbeableto:
1.Explainthekeycontextualfactorswhichhaveanimpactoncounsellingformaternaland
newbornhealth.
2.Analysetheeffectthesefactorsmayhaveonthecounsellingrelationship.
3.Explaintheimportanceofcouplecounsellingandcounsellingonsensitiveissues.
Thecounsellingcontext
Thetermcounsellingcontextdoesnotreferheretothephysicallocationwherecounsellingtakes
place(whichwecallthecounsellingenvironment)butrelatestothesocial,cultural,economic,
religiousandpoliticalfactorsoftheplacewhereyouwork,andthecommunitiesinwhichthe
https://www.ncbi.nlm.nih.gov/books/NBK304177/ 1/15
peopleyouwillcounsel,live.Thissectionexamineshowthesedifferentfactorsmayinfluencethe
counsellingcontext.
Itisimportantforyoutobeawareofthedifferentfactorsthathaveaneffectonthecounselling
contextwithinthecommunityyouwork.Intheprevioussessionswehighlightedhowimportantit
istoassessandunderstandthewoman'sownknowledge,skillsandindividualsituation.Itisalso
importanttoassessandunderstandthewiderculturalandsocialcontextinwhichyouwork.
Economicconditions
Economicstatusreferstoone'sfinancialstatusandisstronglyrelatedtohealthandeducational
status.Soingeneral,mostpeoplewithaloweconomicstatus(e.g.alowincome)arealsolikelyto
havealowereducationalandhealthstatus.
Ontheotherhand,thosewithahighereconomic/financialstatuswillhavebetteraccessto
educationandhealthservicesandwillhavehigherstatusintheseareas.Itisimportanttotakeinto
accountthesocioeconomicstatusofawoman,coupleorfamilybecausethisstatuswillaffectthe
decisionstheyhavetomakeaswellastheneedstheyhave.Forexample,awomanwhoispoor
maynothavemoneytoattendahealthfacility(eitherforchildcare,transportorwhereshemust
payuserfees).Similarlyifawomanhasaloweducationalstatusshemaynotappreciatethe
benefitsofbirthinahealthfacilityandherlowhealthstatusmaymeansheisathigherriskofpoor
healthoutcomesforbothherandherbaby.Educationalstatusisalsorelatedtoliteracy.Youneed
toknowtheliteracylevelofpeoplethatyoucounselsothatyoudonotgivethemcomplexadvice
orinstructionsinwordswhichareunfamiliartothem,materialsthattheycannotread,orforms
whichtheyareunabletounderstandorcomplete.
UNDERSTANDINGAWOMAN'sSOCIOECONOMICSITUATION
Beawarethatthismaybeasensitivetopicforsomewomen.
Tryopenendedquestionsasyoutrytoformanalliance:
I'dliketogettoknowyoualittlemoreperhapsyoucantellmesomethingaboutyourself
andyourhomesituation?
Atothertimesyouwillhavetobemoredirecte.g.Whatlevelofeducationdidyoufinish?
Howdoesyourhouseholdearnitsincome?
Itcanhelpyoutoformanalliancewiththewomanifyouareopenwithheraboutwhyyou
wanttoknowthisinformation.Tellherthatknowingthistypeofinformationwillhelpyouto
tailortheserviceyouprovidetoherspecificneeds.
Socialandculturalcontext
Cultureisatermweusetodescribethevalues,beliefs,practicesandwaysinwhichacommunity
orsocietylives.Italsoincludesthewaythepeopleexpressthemselves,communicate,andinteract
withoneanother.Thesocialcontextreferstohowpeopleareorganized,intermsoffamily
groupings(dotheyliveinextendedornuclear/traditionalfamilies?ordohusbandshaveseveral
wives?)Italsoreferstogroupinteractionsandhierarchieswithincommunities.Forexample,are
theregroupleaders,chiefs,orheadmenorwomen,andwhatroledotheyplay?Theculturaland
socialcontextaffectsallaspectsoflife,fromhowpeoplegreetoneanother,tohowtheyinteractin
thehouseholdandhowtheymakedecisions.
REMINDER
Beingawareofthesocialandculturalcontextwillhelpyouformanalliancewiththewoman
orcoupleyouarecounsellingandwillhelpyoudecideappropriatewaystocommunicatein
termsofhowyouaskquestions,howyouapproachsensitiveissues,andhowyoufacilitate
theprocessofproblemsolving.Itwillalsoenableyoutotailoryourcounsellingtotheir
specificneeds.
Issuessuchasreligionorsocialstatusaffectpeoples'ideasorfeelingsandthiscaninfluence
communicationandcounselling.Theculturalandsocialcontextcanbeexpresseddifferently
dependingonthesettingsuchasthehome,schools,theworkplace,orthehealthservice.Your
professionaltrainingtookplacewithinaparticularperspectiveonhealthandyoumayfeelitisthe
mostappropriatewayofapproachinghealthissues.Othercommunitiesandcultureshavetheirown
waysoftalkingabouthealthwhichmaybedifferentfromyours.Thusitisimportanttoreflecton
whatthesedifferentbeliefsandvaluesare,astheywillhaveanimpactonthewayinwhichyou
interactwithwomenandtheirfamiliesandthewaytheyinteractwithyou.
Pregnancyandbirtharenormallyverysocialandculturaleventsandthustiedtomanyspecific
beliefsandpractices.Inordertobettersupportapregnantwomanandherfamily,itisimportantto
knowthesebeliefsandpractices.Somemaybeverygoodforthewomanandherbaby,othersmay
notbebeneficialbutalsodonoharmyoucanbuilduponthesebeliefsandpractices,andtryto
incorporatethemintoyourpracticeandservice.Otherbeliefsandpracticesmaycauseharm.You
willneedtodiscussthesewiththewomenandherfamilyandthebroadercommunitytoseehow
theycanbechanged.
Activity1
1to2hours
Toassesswhetherlocalpracticesinyourcommunityarehelpful,harmful
orharmlessformaternalandnewbornhealth.
Notetofacilitator:Youcandividethegroupinto3smallergroupsandhaveeachgrouplook
atadifferentaspects,e.g.,onegrouplooksatantenatal,anothergrouplooksatchildbirthand
thethirdgrouplooksatpostnatalpractices.Thenbringthembacktogetherasonelargergroup
todiscusstheirfindings.
Withindifferentculturesorsocialsystemstherecanbeceremoniesorwaystomarkimportant
eventssuchaschildbirth.Forexample,pregnantwomenmaybeexpectedtoactorbehavein
certainways.Theymaybegivenmedicinesorspecialfoods.Theremaybeceremoniesor
activitiestomarkthearrivalofthenewbaby,orpracticescarriedoutduringlabourandbirth.
Understandingthecontextinwhichyouareworkingandcounsellingisveryimportant.This
activitylooksatlocalpracticestohelpyoutoassesssomeimportantaspectsofyourcontext.
Considertalkingtowomenandcommunitygroupstohelpyouanswerthesequestions.
1.Writedowninyournotebookallthelocalpracticesandbeliefsthatyouhavecome
acrossregardingpregnancy,childbirthandthepostpartum/postnatalperiod.Ask
womenorgroupsifthereareanyotherpracticesandbeliefsyoushouldadd.
2.Foreachoneofthepracticesyouhaveidentified,considerwhetheritisgoodforthe
healthofthewomanand/orbaby,ifitisharmlessorharmful.Organizeyourlistof
practicesunderthethreeheadings:
Helpful Harmless Harmful
Youmayneedtofindoutmoreinformationtobeabletomakeyourclassification.A
helpfulpracticeisonethatsupportstheadviceandinformationthatyougivetowomen
(forexample,exclusivebreastfeeding),aharmlesspracticeisonethatdoesnot
contributetoimprovingthehealthstatusofthemotherornewbornbutalsodoesnot
haveadamagingeffect(forexample,beliefs/ritualssurroundingthecareoftheplacenta
afterbirth).Harmfulpracticescoveranythingwhichmightcarryariskofinfection,loss
ofblood,transmissionofanSTIormakethemotherornewbornweak.Harmful
practicesmayalsodelaythewoman'saccesstoappropriatecare(forexample,beliefs
thatannouncingtheonsetoflabourwillresultinanevilspellbeingcast).The
followingquestionsmayhelpyouasyouthinkaboutthis.
a.Doesthepracticeinvolveanimalorhumanwaste?Forexample,acommon
practiceofrubbingmanureontothebaby'sumbilicalcordcancausedangerous
infections.
b.Doesthepracticeinvolveallocatingdifferentamountsoffood,workorrest?For
example,someculturesroutinelygivewomenlesstoeatthanmen.Thiscouldbe
potentiallyharmfultoapregnantorbreastfeedingwoman.Butaculturalpractice
whichencouragesawomanwhorecentlygavebirthtorestinbedcanbehelpful.
c.Doesthepracticeinvolvesexualintercourse?Forexample,sexualcleansing
whereawomanwithSTIshassexwithatraditionalmedicinepractitioneris
unlikelytodoanygood,andcantransmitSTIs/HIVifcondomsarenotused.
However,sexualintercoursebetweenawomanandherhusbandduring
pregnancyisharmless,unlessoneorbothofthecoupleareHIVpositiveandare
notusingcondoms.
d.Doesthepracticeinvolvetakingbloodfromthewomanoutsideofthehealth
service?Forexample,takingbloodfrompregnantwomentocleanseherof
demonscouldbeharmfulasthereisriskofinfectionandtoomuchbloodcould
betaken.
e.Doesthepracticeinvolvelocalherbs,remediesormedications?Forexample,
takinglocalremediestostimulatecontractionscouldbeharmful,butotherherbs
orfoodstopromotebetternutritionmightbeharmlessorhelpfuldependingon
theingredients.
f.Doesthepracticeinvolvedelaysinreachingaskilledattendant?Forexample,the
beliefthatinfidelitycausesobstructedlabourmayresultinreluctancetogive
birthinahealthfacility.
3.Thinkabouthowyoumightincorporatesomeofthehelpfulandharmlesspracticesinto
youradviceandcounsellingwithpregnantwomenandtheirfamilies.Thinkabouthow
youwilldiscusstheharmfulpracticeswithwomen,theirpartnersandtheirfamiliesand
thecommunitysoyoucanimproveyourmutualunderstanding.
OurView
Yourlistwillbedividedintothosepracticeswhicharehelpful,forexample,apregnant
womanshouldbegivenanadditionalportionofmeatorfishtohelpherstaystrong.They
couldbeharmlesspractices,suchastheplacentaafterbirthshouldbeburied.Ortheycould
beharmful,suchasputtingcowdungontheumbilicalcord.Whetherhelpful,harmlessor
harmful,youshouldtrytobetterunderstandthepracticeandbelief.Wherepracticesare
helpful,theyshouldbeencouraged.Whereharmless,thereisnopointindiscouragingthem.
Youmayfindyougetmorerespectandbettersupportfromthecommunityifyourespecttheir
harmlesspracticeswhichmayhavegreatsignificancetothemandtheirculturalandsocial
context.
Discusswithwomen,theirfamiliesandothersinthecommunitythosepracticeswhichare
harmfulorwhichcouldendangerthehealthofthemotherornewborn.Listentotheir
explanationsaboutthepracticeanddiscussthereasonswhythepracticeisharmful.Inmany
situationsareplacementharmlesspracticecanbesubstituted,insteadoftheharmfulpractice.
Inthecaseoffemalegenitalmutilation,forexample,youcouldstillconductapassageof
ritesceremonybutsimplyreplacethewordsinthetraditionalsongusedduringtheceremony
andprovideabeadednecklaceorsomeculturallysuitablesymbolinsteadofperformingthe
cuttingceremony.
REMINDER
Manypracticesaredeeprootedinsocialandculturalnormsandgenderrolesandperceptions.
However,healthworkerscanplayanimportantroleinstimulatingdiscussionsontheseissues
inthecommunity.
Genderroles
Twoofthedifferencesbetweenmenandwomenaresexandgender.Sexisthephysical,biological
differencebetweenwomenandmen.Itreferstowhetherpeoplearebornfemaleormale.Gender,
isnotphysicallikesex.Genderreferstotheexpectationspeoplehavefromsomeoneora
communitybecausetheyarefemaleormale.Genderattitudesandbehavioursarelearnedandthe
conceptcanchangeovertime.Sexisbiologicallydeterminedwhilegenderissociallydetermined
intermsoftherolesandresponsibilitiesthatsocietyorfamilyassignstowomenandmen.
Menandwomenusuallyaccepttherolesdefinedandperpetuatedbytheircommunitywhichcan
havebothadvantagesanddisadvantagesforthem.Therearemanyfactorsthatinfluencegender
roles.Theseinclude:age,culture,maritalstatus,education,economics,profession,andthecountry
orsocietyitself.Understandingthegenderrolesinthecommunitycanhelpyoutobetter
understandthesituationofthewomenandmenyoucounsel,andthusimproveyourcounselling
interactions.
Understandinglocalgenderrolesandhowtheyaffectmenandwomeninyour
communitycanimproveyourcounsellinginteractions
EXAMPLESOFGENDERROLES
Womenshouldstayathomeandlookafterthehomeorfamily.
Menshouldnotdohousework.
Menshouldnotcry.
Womenshouldnotdisagreewiththeirhusbands.
Womenshouldkeeptheirbodiescovered.
Womenshouldnotdrinkalcohol.
Howarewomenandmenexpectedtothink,feelandactinyourcommunity?Howdotheylearn
todothis?Genderrolesarelearnedfromayoungageasparentsmaytreatgirlsandboys
differently.Inaddition,childrenoftencopythebehaviouroftheirparents.
Manywomenfindthegenderroleofwife,motherandhousekeeperverysatisfying,providing
themwithstatusinthecommunity.However,itcanbeadisadvantagetootherwomenwhowant
tohaveonlyafewchildrenorwanttopursueacareerorotherinterests.Somewomenmanageto
combineanumberofdifferentroles.Forthefamilyandthecommunityitcanbebeneficialfor
womentolookafterthechildrenandremainathome,butitcouldalsobeadisadvantageas
womenwhohavepaidemploymentcouldbringotherbenefitstothefamilyandcommunity.
Genderrolesalsoteachmenandwomentoexpressthemselvesdifferently.Womenareoften
allowedtobemoreemotionalwhereasmenaretaughttokeeptheirfeelingsinside.Menmayget
lesssupportwhentheyhaveproblemsduetoexpectedgenderroles.Sometimesitwillbeimportant
foryoutocounselmenanditwillbeparticularlyimportanttotakeintoaccountthecommunity's
normsforgenderrolesasyoudoso.Forexample,awomanmaywantherpartnerorhusbandto
bepresentwhenshegivesbirthbutthemanmayfeelpressurefromothersinthecommunityor
fearthereactionofothersinacommunitywherethisisnotusualpractice.
Similarlywecanseeexamplesofgenderrolesinthecommunity.Insomecommunitiesthe
opinionsofmenmaybevaluedmorehighlythanwomen'sopinions.Womenmaynotbe
encouragedtospeakorparticipateindiscussions.Thismeansthatthecommunityhearsmoreabout
whatmenthinkaboutproblemsandissues.Thecommunityorfamilymaynotbenefitinthis
situationaswomen'sknowledgeandexperienceareundervaluedoroverlooked.Youmayneedto
beawareofthiswhenyouworkwithcommunities,inordertosupportwomentoshare
information,anddiscusstheirknowledge.
EXAMPLESOFGENDERINEQUALITIES
Womenmakeuptwothirdsoftheilliteratepopulationintheworld,andinmany
countries,thereexistsagendergapineducationfarfewerwomenthanmenare
educated.
Womencarryouttwothirdsoftheworld'swork,butearnonlyonetenthoftheworld's
income.
Maternalmortalityindevelopingcountriesis22timesgreaterasanaveragethanin
developedcountries.
Inmanyplaces,womenaretwiceaslikelytoworkfornothingasmen.
Thinkaboutthesestatements.Youmayliketousethemasadiscussionpointwiththe
communitywhenyoudiscussgenderrolesandinequality.
Source:PopulationCouncil.Aclientcenteredapproachtoreproductivehealth.Atrainer's
manual.Islamabad,Pakistan:2005..
Theimpactofgenderrolesonhealth
Genderroleshaveanimpactonbeliefs,attitudesandvalues.Genderrolescanalsogreatlyaffect
healthbehaviourandthesexualandreproductivehealthofmenandwomeninyourcommunity.
Forexample,insomecommunitiesadolescentsareencouragedtohavesexwitholdermenthus
genderrolescaneffectthetransmissionofSTIsincludingHIV/AIDSandcanalsoleadto
unwantedpregnancies.Genderrolescanleadtootherundesirablesexualbehaviourssuchas
womenhavingsexwhentheydonotwantto,andevenrapeandviolenceagainstwomen.
Alternativelygenderrolesmayprohibitwomenfromexpressingtheirownsexualneedsordesires.
Genderrolescanhaveanimpactondecisionmaking.Forexample,insomesocietieswherethere
isafemalehierarchy,youngmotherswillnotbeallowedtotakedecisionsaboutseekingcareon
theirown.Thismaynotalwaysbenegative.Incertaincases,adolescentgirlsmaywantsupport
fromolderwomenintakingdecisions.
Householddecisionmakingprocesses
Peopledonotmakedecisionsinisolationfromthecontextoftheirlives,andthisincludesasking
advicefromotherfamilymembersandeventhewidercommunity.Researchhasshownthatboth
thecontextinwhichdecisionmakingoccursandthesocialinfluencessuchasthoseofapartneror
thefamily,oftenhavemoreeffectondecisionmakingthanmerelyinformationandeducationor
theprovisionofcommunicationmaterials.
Youmayneedtofacilitatethedecisionmakingprocessamongallthoseinthehouseholdwhohave
importantcontributionstomake.Culturalpracticesandgenderrolesoftenheavilyinfluencethe
decisionmakingprocess.Awomanmaybeunwillingtocommittoaplanofactionortakea
decisionuntilshehasdiscussedtheissueswithherpartnerorotherfamilymemberssuchasher
motherormotherinlaw.Youcansupportwomeninthesediscussionsbyreviewingthe
advantagesanddisadvantagesofdifferentoptionsandherneedsinthatsituation.
ANEXAMPLEOFCOUNSELLINGWITHINTHECONTEXTOFHOUSEHOLD
DECISIONMAKING
Situation:Counsellingawomanabouttheneedtoexclusivelybreastfeedherbabyuptosix
months.
Problem:Hermotherisencouraginghertointroduceporridgeatthreemonths.
Process:
1.Establishwiththewomanwhatshewantstodothroughopenquestioningandactive
listening.
2.Reviewtheadvantagesanddisadvantageswithhertohelphermakeherdecision.
3.Ifshewantstocontinuebreastfeedingexclusivelythenfacilitatetheprocessof
generatingoptionsofhowshecanaddressthissubjectwithhermother.Shemightwant
informationfromyoutogivetohermothershemaywanthermothertojoinyouina
discussionshemaywanttopractisedifferentscenarioswithyou.
Activity2
45minutes
Toassesshowgenderrolesandhouseholddecisionmakingcontributeto
thehealthofthewomenyousee.
Thisactivityexploresthecontextofgenderrolesandhouseholddecisionmakingandhow
theseimpactonmaternalandnewbornhealth.
Notetofacilitator:considersplittingthegroupupintosmallergroupsandgivethem
differentpartsoftheactivitytocomplete,whichtheycanthensharewiththewhole
group.
1.Aretheredifferentwaysinwhichwomenandmenareexpectedtobehaveinthe
community?
2.Dothesedifferentpatternsofbehaviourdependontheageormaritalstatusofwomen?
3.WhatimpactmightthesebehaviourshaveonMNH?
4.Whatotherreproductivehealthproblemsmighttheserolescontributeto?
5.Whatcanyouasahealthworkerdo,inacounsellingsessionorduringyour
interactionswiththecommunity,tohaveanimpactongenderrolessothatwomencan
bettercareforthemselvesandtheirbabies?
6.Ingeneral,inyourcommunity,howaredecisionsinthehouseholdmaderegardingthe
careofapregnantwoman?
7.HowdoesthisaffectMNH?
8.Howmightyousupportwomeninthedecisionmakingprocessintheirhomesabout
MNH?
9.Howmightyouincludeotherkeyfamilyorcommunitymembersinthecounsellingand
decisionmakingprocesses?
OurView
Somegenderrolesareinfluencedbyreligiousbeliefswhileothergenderrolesarebasedon
traditionsorculture.Socialnormsandgenderrolescanleadtowomennotvaluingtheirown
bodies,ornotunderstandinghowtheirbodieswork.Thismeanstheydonotknowwhatto
expectorwhatisnormal.Sometimesgenderrolescanleadtowomenpayingmoreattention
tothesexualneedsanddesiresofmenthantotheirownneeds.Thiscanleadtounwantedsex
orhavingsexbyforceortowomennotusingcontraceptivesbecauseofpressurefrommen.
OtherreproductivehealthproblemsmayarisesuchasSTIs.
Youcanplayanimportantroleinteachingwomenaboutthedifferentpartsoftheirbodiesand
therolethattheyplayinsexandreproduction.Discusswithwomenwhatisnormal(for
example,routinevaginaldischarge)andwhentheyneedtoseekcare(incasesofabnormalor
infectedvaginaldischarge).Youcanalsosupportwomentotakemorecontrolovertheirlives
sothattheycannegotiatesafersexpracticesandcontraceptionandparticipateindecision
making,especiallywhereitconcernstheirsexualhealth,orthehealthoftheirbaby.
Somecommunitieshavenegativeviewsaboutwomen'sbodies.Forindividualwomenthiscan
leadtofeelingsofshameandalackofknowledgeoftheirownbody.Problemscanarisebecause:
Womenareembarrassed.
TheydonotknowhowtoprotectthemselvesfromSTIsorunwantedpregnancy.
Theyarenotincontroloftheirownsexualhealthdecisions.
Helpwomentounderstandhowtheirbodiesworkinrelationtosexualandreproductivehealth.If
itissociallyandculturallyappropriate,helpthemtoexploretheirsexualitywhichincludestheir
feelingsandattitudestowardssexualrelations.
Recognizewhenitisimportanttoincludepartnersandotherfamilymembersincounsellingfor
MNH.Alsosupportwomeninhowtodealwithfamilyinvolvementintheirdecisions.Dothis
throughinteractivediscussionswiththewomen.Sometimesyoumayneedtoworkwithpartners
orotherfamilymembersintheabsenceofthewoman(forexample,whensheistooilltotake
decisionsonherown).Yourskillisinsupportingherindeterminingwhoshouldbeinvolvedinthe
decisionmakingprocess.Butremembertorespectconfidentialityintermsofthewoman'swishes.
REMINDER
Involvingthepartnerandotherfamilymembersincounsellingmayrequireadditionaltime
andresources.However,ifyouonlycounselawoman,thedecisionsshemakesmaybe
overruledlaterbyherfamily.
Activity3
34hours
Toexplorethecounsellingcontextinyourcommunity.
BeforemovingontoPart3ofthisHandbookwhereyouwillexaminetopicsandpractice
skills,youmaybenefitfromamoreindepthexplorationofthecounsellingcontextinyour
community.
Notetofacilitator:dividetheworkofthisactivityamongthegroup.Getthemtoplan
anddecidewhowillintervieweachdifferentcommunitygroup(asoutlinedinnumber
1),andtoagreehowtheinterviewsshouldbeconductedandwhichquestionstoask.
1.Setupinterviews,meetingsorinformaldiscussionswithreligiousleaders,traditional
healers,chiefs,andpoliticalleaders,inadditiontootherhealthprovidersandmembers
ofthecommunity.
2.Makeaguideofsomeofthequestionsandtopicareasyouwouldliketodiscussin
advance.Thetopicsyouexploremightincludeareassuchas:
a.Localcultureandsocialsystems
b.Politicsandreligion
c.Poverty
d.Genderroles
e.Familystructureandhouseholddecisionmaking
f.Womenwithspecialneeds
g.Localbeliefsandpracticesrelatedtomaternalandnewbornhealth
h.Opinionsaboutthehealthservice.
3.Takenotesofthediscussionandsharethemwithyourcolleaguesimagineyouare
tryingtoexplainthecontexttosomeonenewthathasneverbeentoyourcommunity
before.
4.Discusshowyourfindingsmighthaveanimpactonmaternalandnewbornhealth.
OurView
Youmayfindthatyouareworkingwithacommunitywherethecontextisthesameforthe
majorityofthepopulation.Oryoumightfindthatyouworkinacommunitywherethereare
lotsofdifferencesforexample,acommunitywherethereismorethanonedominantreligion,
tribeorethnicgroup.Differentgroupsinthecommunitywillviewmaternalandnewborn
healthandreproductivehealthindifferentways.Itisimportanttounderstandallthedifferent
factorsandviewsthatcontributetothesocialandculturalcontextoftheareawhereyou
work.Understandingthecontextthatcommunitiesliveincanhelpyoutocounselmore
effectivelyasyouwillunderstandthecontextinwhichdecisionshavetobetakenandhow
thecontextmayaffectmaternalandnewbornhealth.
Withthisunderstanding,youcanbetterfacilitateprocessesforwomenandtheirfamiliesto
findculturallyandsociallyacceptablesolutionsfortheirproblems.Bydoingthistheyare
morelikelytobeabletofollowtheactionanddecisionstheyhavetaken.
Couplecounselling
Justasitisimportanttoconsiderthehouseholddecisionmakingprocesses,therearemanytimes
duringcounsellingformaternalandnewbornhealthwhereyouwillneedtoworkwithcouples
thewomanandherpartner/husband.Therearesomeobviousinstancessuchascounsellingabout
familyplanningwhereyoucouldworkwithacouple,butthereareothertimesalsosuchaswhen
youcounselaboutcareduringpregnancy,discusssupportduringlabourorfollowingbirth.
Whencounsellingacoupleitisimportanttoacknowledgethattheymaynothavethesame
attitudes,beliefsandvalues.Theymaynotevenhavethesameperceptionoftheproblemorneed
thatyouarediscussing.Theymayhavedifferenteducational,socialandliteracylevels,andthisis
particularlytrueifculturegenderrolesinyourcommunitydonotsupportwomen'seducation.
Thereforeyoucannottreatthemasacouple,butratheryoumusttailoryourcounsellingskillsto
twoindividualswhoneedtoreachamutualdecision.
Youmayfindthatyouwanttoagreeordisagreemorestronglywithoneofthecouplecomparedto
theother.Thisiswheretheprinciplesofselfreflection,andempathyandrespectcomein.You
needtobeawareofhowyourownattitudes,valuesandbeliefs(whichareshapedbythecultural,
socioeconomicandgendercontextthatyoulivein)affectthewayyouthink.Evenifyoudisagree
withoneofthecouple,youmustmaintainyourrespectforthatperson'spointofview.Itisnot
yourroletosupporteitherthemanorthewomanintheargument.
Itmaybeimportanttoincludeherhusband/partnerinthecounsellingprocess
Ifyoucanformanalliancewithbothpartners,itallowsforasituationoftrustandmutualrespect.
Youcanthenfollowthestepsinthecounsellingprocess,makingsureyougivethembothanequal
chancetoparticipateinthediscussion.Itispossiblethatsometimeswhenyoucounselacouple,the
situationmaybecomeheatedwithonepersonbecomingabusiveoraggressive.Itcanbeagood
ideainthesesituationstospendtimewitheachpersonindividuallybeforebringingthemtogether
sothattheybothhaveachancetotalkfreely.Whenyoubringthemtogetheryoucantakesome
timetoagreeuponsomegroundrulesforyourdiscussion.
EXAMPLEOFGROUNDRULES
Nointerruptingoneanother
Noshoutingoraggressivebehaviour
Mutualrespect
Consideralloptionsbeforediscardingthem.
Indecidinguponthesegroundrulestogetheryoualsohavetotakeintoaccountwhatis
appropriatesociallyandculturallyintermsofhowmenandwomenbehave.
Counsellingonissuesofsexuality
Formosthealthcareproviders,sexualitywillprobablybethemostdifficultandchallengingareaof
counsellingduringpregnancyandthepostpartumperiod.Weareallreasonablycomfortabletalking
aboutSTIsandfamilyplanningmethods,butdiscussingandcounsellingforothersexualityissues
andinparticularsexualintercourseismorechallengingandasaresultoftenavoided.Thereare
manyprioritiesintheprovisionofgoodhealthcaretowomenduringpregnancyandchildbirth
suchaspreparingforthebirth,learningwhatdangersignstolookfor,allaimedatreducing
morbidityandmortalityfrompregnancyandchildbirthandprovidingwomenwithgoodcare.Itis
easyforissuesofsexualitytobeputtooneside.Incomparisontootherclinicalconditions,they
arenotashighontheprioritylistforprovidinggoodcare.
However,sexualityissuesdocontributetoanxietyformanywomeninpregnancyandafter
birth.Thereisoftenlittleopportunityfortheseanxietiestobeallayedorevendiscussed.Thisis
mostlyduetoourownlimitationsindiscussingmattersofsexualityfranklyandopenly.Thereis
alsoalackofevidenceinthisarea,whichmeansthat,thereislittleclearguidance.
Manywomenwillnotneedextensivecounsellingaroundsexualityissues.Itisusefulforthehealth
careprovidertogivewomenanopportunitytodiscusssexualityissueswhenappropriate.Giving
womentheopportunitytodiscusssexualitycanbedonesimplybyquietlysayingtoawomanthat
ifshehasanyproblemsorquestionsofanykindduringherpregnancyorafterbirth,including
thingsthatshemaynotfeelabletotalkabouttootherpeople,shecandiscussthemwiththe
counsellor.
Wehavealreadymentionedtheimportanceoftheculturalandsocialcontextincounselling.Thisis
particularlyimportantregardingsexualityissues.Mostculturesandsocietieshavewelldefined
attitudesaboutsexuality,andalsowelldefinedideasastowhatsexualpracticesareacceptable.
Manyofthesesocialattitudesormoralsarecloselylinkedtothereligiouspracticeswithina
community.Manyreligioustextsprovideclearguidanceonsexualityissuesduringpregnancy.
Counsellingaroundsexualityissuesshouldalwaysstartwithyoufamiliarizingyourselfwiththe
culturalandreligiouscontextandthespecificinformationneededaroundthesexualitypracticesof
eachcommunity.Ifyouarefromthecommunityinwhichyouarecounsellingthenyoumay
alreadybefamiliarwithmanyofthelocalpractices.Ifyouarenotfromthecommunitythenthis
informationcansometimesbelearntfromotherhealthcareproviders,fromtheelderwomen,or
otherrespectedpeopleinthecommunity.Insomecommunitiessexualityisnotanopensubjectand
evengatheringinformationaboutsexualpracticesneedstobedonerespectfullyandsensitively.
Differentcommunitiesusedifferenttermsforsexualintercourse.Forexample,somecommunities
wouldnotbecomfortablewiththetermsexualintercourseorsexandmayprefertosay
sleepingtogether.Usingthesametermsandnamesthatareacceptableinacommunity
demonstratesrespectforthecommunityandmaybeausefultooltopavingthewayforopen
discussion.Itwouldbeappropriateforyoutosupportlocalsexualpracticesthatarenotharmful.
Forexample,manycommunitiesprohibitsexualintercourseatdifferenttimesduringpregnancy.
Whilethereislittleevidencetoprohibitsexualintercourseinanuncomplicatedpregnancy,itwould
notbeharmfulforcouplestofollowtheircommunitysexualpracticeinthisinstanceandtherefore
youcansupportthispractice.However,itwouldbeinappropriateforyoutoactivelysupport
harmfulsexualpracticessuchasFemaleGenitalMutilation(FGM).
Manyofthequestionsandconcernsthatwomenhaverelatedtosexualityissuesduringpregnancy
arerelatedtothephysiologicalchangesofpregnancy.Forexample,womenmaythinkthatthe
normalincreaseinvaginaldischargethathappensduringpregnancy(leucorrhoea)isasignofan
STI.ProvidingthisinformationaswellasscreeningandtestingforSTIsisimportant.Womenare
alsooftenunpreparedforthechangesintheirsexualdesireduringpregnancy.Thischangesas
pregnancyprogresses:duringthefirstpartofpregnancywhenwomenareoftenfeelingnauseated
andsicktheirdesireistypicallyreducedinthemiddlepartofpregnancywomenoftenfeelmuch
betterandthereforetheirdesirereturnstonormalinthelastpartofpregnancywomenfeelvery
uncomfortableduetothesizeofthebabytheyarecarrying,theyaretiredandtheirinterestinsex
decreases.Thesechangesareallrelatedtothebodyprocessesinpregnancyandarenormal.They
alsomayvarygreatlyfromwomantowoman.
Counsellingduringpregnancyislimitedbytimeandsometimestheenvironmentmaynotenable
youtospeaktoawomanaboutsensitiveorprivatetopics.Sometimesthebarriersoflanguage,
cultureoragemaybecomeabarrierbetweenyouandthewoman,particularlyindiscussing
sexualityissues.Insuchinstancesitwouldbeappropriateforyoutoencouragethewomantoopen
upperhapstoanotherhealthcareproviderorcommunityleader.
Intalkingaboutsexualityissuesyoumayencounterasituationwhenawomandisclosesasexual
problemthatyoufeelunabletodealwith.Examplesofthismaybeawomanwhodisclosesabuse
orincestoracouplewhohavealongstandingsexualdysfunction.Inthissituationitwouldbe
appropriateforyoutoseekhelpfromanothermoreexperiencedcounsellororsomeonewith
specialexperienceinthesematters.
Noteforworkinggroupfacilitator
Thekeyissueistotrytopreventtheworkinggroupfromtotallydismissinganyneedfor
counsellingaroundsexualityissuesbecausetheyhavebeenoffendedbysomeofthesuggestionsin
theHandbook.Theroleofthefacilitatoristoencouragetheworkinggrouptovoicetheirconcerns
onthistopic,demonstratethattheseconcernsarerespectedandthatlocalcustomwillguidethe
counselling.Atthesametimethefacilitatorsshouldtrytoensurethatcounsellingaroundissuesof
sexualityisconsideredtobevaluableandnotabandoned.Itisusefulforthefacilitatorto
acknowledgetheimportanceofcounsellingonissuesofsexualityandthepotentialbenefitsto
pregnantwomenasoutlinedinthehandbookandtoconsiderthatlocalcustomandtaboos,
sometimesinfluencedbygenderdiscriminationmaybeapotentialbarriertoprovidingwomenwith
importantcounselling.
WhatdidIlearn?
Aftercompletingthissessionyoushouldbemoreawareofthewidercontextofcounselling
andkeyfactorsthatcanaffectit.Theseinclude:socioeconomicstatus,culture,genderroles,
traditionalpractices,andthewidersupportanddecisionmakingnetworkfromthepartner,
familyandcommunity.Youhavealsoconsideredhowtoimproveyourskillsincouple
counsellingandcounsellingonsensitiveissuesaroundsexuality.
Progresscheck
DoIunderstandtheinfluencegender,thesocioeconomicsystemandculturehaveon
maternalandnewbornhealthinmycommunity?
HowcanIdiscusspracticesandbeliefswhicharenotharmful?
HowcanIdiscusspracticesandbeliefswhichareharmful?
WhatarethedifferentwaysIcanfacilitatethedecisionmakingprocesswithcouples
andotherfamilymembers?
HowcanIaddresssexualityconcernsofwomenduringpregnancyorafterbirth?
CopyrightWorldHealthOrganization2013.
Allrightsreserved.PublicationsoftheWorldHealthOrganizationcanbeobtainedfromWHOPress,WorldHealth
Organization,20AvenueAppia,1211Geneva27,Switzerland(tel.:+41227913264fax:+41227914857email:
bookorders@who.int).RequestsforpermissiontoreproduceortranslateWHOpublicationswhetherforsaleorfor
noncommercialdistributionshouldbeaddressedtoWHOPress,attheaboveaddress(fax:+41227914806email:
permissions@who.int).
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