Adaptation Guide Counselling Handbook

A handbook for building skills
Counselling for Maternal

and Newborn Health
Adaptation Guide
Updated 2014
TABLE OF CONTENTS
ACKNOWLEDGEMENTS ................................................................................................................................ III

ABBREVIATIONS ........................................................................................................................................... IV
1. INTRODUCTION ........................................................................................................................................... 1
2. ABOUT THE MNH COUNSELLING HANDBOOK ............................................................................................ 2
2.1 BACKGROUND .................................................................................................................................................................. 2
2.2 DEVELOPMENT.................................................................................................................................................................. 2
2.3 CONTENT .......................................................................................................................................................................... 3
2.4 KEY PRINCIPLES ............................................................................................................................................................... 4
2.5 INTENDED USERS.............................................................................................................................................................. 5
3. ADAPTATION PROCESS ............................................................................................................................. 5
3.1 ASSESSING THE NEED TO ADAPT ..................................................................................................................................... 5
3.2 PROCESS OF ADAPTATION ............................................................................................................................................... 6
3.2.1 Appoint an Adaptation Committee ..................................................................................................... 7
3.2.2 Develop the Terms of Reference ....................................................................................................... 7
3.2.3 Review the MNH Counselling Handbook ............................................................................................ 7
3.2.4 Adaptation....................................................................................................................................... 8
3.2.5 Align with National Policies ............................................................................................................... 9
4. TRANSLATION ............................................................................................................................................. 9
5. SUGGESTED ADAPTATIONS ...................................................................................................................... 9
5.1 LINKS WITH PCPNC ......................................................................................................................................................... 9
5.2 CONSIDERATIONS FOR ADAPTATION............................................................................................................................... 11
5.3 CULTURAL CONSIDERATIONS ......................................................................................................................................... 12
5.3.1 Counselling Skills (Session 3) ..........................................................................................................12
5.3.2 Factors influencing the Counselling Session (Session 4) .....................................................................12
5.3.3 Support during Labour and Childbirth (Session 10).............................................................................13
5.3.4 Death and Bereavement (Session15)................................................................................................14
5.4 ILLUSTRATIONS ............................................................................................................................................................... 14
5.5 LOCAL TERMINOLOGY AND CONCEPTS........................................................................................................................... 15
5.6 LEGAL, HUMAN AND REPRODUCTIVE RIGHTS……………………………………………………………………………...16
5.6.1 Post-Abortion Care (Session 9) ........................................................................................................16
5.6.2 Women and Violence (Session 16) ...................................................................................................16
5.7 CONSISTENCY WITH NATIONAL PROTOCOLS AND GUIDELINES ....................................................................................... 16
5.7.1 Counselling Paradigms (Sessions 2-5) ..............................................................................................17
5.7.2 General Care (Session 6) ................................................................................................................17
5.7.3 Birth and Emergency Planning (Session 7) ........................................................................................17
5.7.4 Family Planning Counselling (Session 12) .........................................................................................18
5.7.5 Breastfeeding (Session 13) ..............................................................................................................18
5.7.6 Women with HIV/AIDS (Session 14) .................................................................................................19
5.8 PRIORITY MATERNAL AND NEWBORN HEALTH ISSUES NOT ADDRESSED ........................................................................ 19
5.8.1 Female Genital Mutilation (FGM) ......................................................................................................19
5.8.2 Obstetric Fistulae ............................................................................................................................20
5.8.3 Malaria ..........................................................................................................................................20
5.8.4 Adolescents and Women with Special Needs ....................................................................................21
6. BUILDING CONSENSUS FOR ADAPTATION ................................................................................................22
7. FIELD TESTING ..........................................................................................................................................22
WHO Adaptation Guide for MNH Counselling Handbook i

8. IMPLEMENTATION ......................................................................................................................................23
9. MONITORING AND EVALUATION ...............................................................................................................25
10. ADAPTATION BIBLIOGRAPHY ..................................................................................................................27
11. REFERENCES ..........................................................................................................................................27
ANNEX 1 .........................................................................................................................................................29
ANNEX 2 .........................................................................................................................................................36
ANNEX 3 .........................................................................................................................................................46
BOX 1 MNH COUNSELLING HANDBOOK'S OBJECTIVES ................................................................................................................ 1

BOX 2 MNH COUNSELLING HANDBOOK'S TOPICS ........................................................................................................................ 3
BOX 3 TRANSLATION TIPS ............................................................................................................................................................ 9
TABLE 1 PCPNC LINKS TO ADAPTATION GUIDE & MNH COUNSELLING HANDBOOK .................................................................. 10
TABLE 2 SUMMARY TABLE: CONSIDERATIONS FOR ADAPTATION ................................................................................................ 11
TABLE 3 POTENTIAL LANGUAGE BARRIERS................................................................................................................................. 15
TABLE 4 EVALUATING THE MNH COUNSELLING HANDBOOK ....................................................................................................... 26
FIGURE 1 SCHEMATIC OVERVIEW OF THE COUNSELLING PROCESS.............................................................................................. 4

FIGURE 2 FLOW DIAGRAM: SUGGESTED ADAPTATION PROCESS……………………………………………………………………. 6
WHO Adaptation Guide for MNH Counselling Handbook ii

Acknowledgements
This Adaptation Guide for "Counselling for Maternal and Newborn Health: A handbook for building skills" was
written by Hannah Ashwood-Smith, with technical support from Annie Portela (World Health Organization Department
of Maternal, Newborn, Child and Adolescent Health (WHO/MCA). The Guide was updated in 2014, by Pooja Pradeep,
intern to WHO/MCA, to reflect the updates made to the MNH Counselling Handbook.
Valuable inputs were received from Yolande Coombes, independent consultant and Margareta Larsson, Ornella
Lincetto, Matthews Matthai, Juliana Yartey, and Jelka Zupan of WHO/MCA. In addition, Heather Brown provided input
on the sections about sexuality, and Nasr Abdallah of Sudan provided comments regarding cultural considerations.
The first draft was edited by Pat Coppard and Barbara Ashwood-Smith. The final draft was edited by Annie Portela and
Karen Mulweye, WHO/MCA.
MCA/WHO gratefully acknowledges the contribution of the teams who conducted the field reviews for the
"Counselling for Maternal and Newborn Health: A handbook for building skills" (MNH Counselling Handbook) in
Malawi, Indonesia, Sudan and the Philippines. Many of the suggested recommendations in this document draw from
this body of work. The enthusiasm, motivation and commitment of the Skilled Attendants interviewed were paramount
to the development of the MNH Counselling Handbook and to this technical adaptation guide.
WHO Adaptation Guide for MNH Counselling Handbook iii

Abbreviations
AIDS Acquired immunodeficiency syndrome
ANC Antenatal care
ARV Antiretroviral drug
BEOC Basic emergency obstetric care
CEOC Comprehensive emergency obstetric care
FGM Female genital mutilation
FP Family Planning
HIV Human immunodeficiency virus
IEC Information, education and communication department
IUD Intrauterine Device
LAM Lactational Amenorrhoea Method
MCA Maternal, Newborn, Child and Adolescent Health
MCH Maternal and child health
MNH Maternal and Newborn Health
PCPNC Pregnancy, Childbirth, Postpartum and Newborn Care: A Guide for Essential
Practice
PLPWA People Living Positively with AIDS
PMTCT Prevention of mother-to-child transmission
SAs Skilled Attendants
STIs Sexually transmitted infection
TB Tuberculosis
TBAs Traditional Birth Attendants
WHO World Health Organization
WHO Adaptation Guide for MNH Counselling Handbook iv

1. Introduction
The World Health Organization (WHO) developed a clinical guide entitled “Pregnancy, Childbirth,
Postpartum and Newborn Care: A guide for essential practice” (PCPNC). The aim of the PCPNC is
to provide evidence-based recommendations to guide health care professionals in the
management of women during pregnancy, childbirth, postpartum and post-abortion periods, and
newborns during the first week of life, including management of endemic diseases like malaria,
HIV/AIDS, TB and anaemia. All recommendations are for Skilled Attendants (SAs) who work at the
primary level of care, in health facilities or in the community. While the PCPNC serves as a guide
for clinical decision-making and includes recommendations on the information to share with women
and their families, little guidance is included on how to effectively communicate and counsel.
Many countries have documented weak communication and counselling skills in health workers as
a major deterrent to health service use (Nicholas et al, 1991: Jaacobsen, 1991; Ashwood-Smith et
al, 2000). Evidence-based information provided to practitioners and training strategies to
strengthen their clinical skills need to be complemented by strategies geared towards improving
their inter-personal and inter-cultural skills. Studies examining quality of care factors in maternity
facilities have identified improving communication and counselling skills as a priority for improving
access to, and utilization of, quality maternal and newborn health (MNH) services (WHO, 2003;
Hulton et al, 2000; Jaacobsen, 1991; Ashwood-Smith et al, 2000). Improved interpersonal
communication and intercultural competence of health care workers result in greater client
satisfaction levels, higher compliance with treatments, more accurate diagnoses, positive
outcomes, enhanced perceptions of quality of care, and overall increased service use (WHO, 2003;
Brown et al, 1995; Young Mi Kim et al, 2001).
It is therefore important to consider how to support SAs in providing the many recommendations for
women and their families included in the PCPNC: With this goal in mind, the WHO Department of
Maternal, Newborn, Child and Adolescent Health (WHO/MCA1) developed “A handbook for building
skills: counselling for maternal and newborn health” for SAs. The main aim of this practical
Handbook (herein referred to as the MNH Counselling Handbook), and companion to the PCPNC,
is to strengthen SAs' counselling and communication skills, helping them to effectively convey to
women, families and communities the key issues surrounding pregnancy, childbirth, postpartum
and postnatal care highlighted in the PCPNC. Box 1 below, describes the MNH Counselling
Handbook’s primary objectives.
Box 1 MNH Counselling Handbook's Objectives
MNH Counselling Handbook’s Objectives:
The SA should learn how to:
1. Understand the women and community he/she provides services for; both the overall context in which they live as
well as their specific needs.
2. Counsel and communicate more effectively with women, their partners and families during pregnancy, childbirth,
postnatal and post-abortion periods.
3. Use different skills, methods and approaches to counselling in a variety of situations, with women, their partners
and families in effective and appropriate ways.
4. Support women, their partners and families to take actions for better health and facilitate this process.
5. Contribute to women and the communities’ increased confidence and satisfaction in the services he/she provides.
1
formerly the Department of Making Pregnancy Safer
WHO Adaptation Guide for MNH Counselling Handbook 1

The MNH Counselling Handbook can be utilized as it stands, or tailored to meet a country’s
specific needs. The present document serves as a technical adaptation guide for the MNH
Counselling Handbook, developed to help programme managers, policy makers and reproductive
health specialists analyse the MNH Counselling Handbook, exploring potential areas for change. It
describes the key principles, purpose and objectives of the generic MNH Counselling Handbook. It
explores a methodology for countries to adapt its content to suit their local country’s context. It
covers recommendations, drawn in part from WHO documents on technical adaptations (WHO,
2007; WHO, 2005; Church, 2006) and includes specific examples extracted from the field reviews
conducted in four countries in Africa and Asia. The final section of the guide contains the
bibliography and references (annex 1) for the MNH Counselling Handbook, an overview of the
methodology and samples of tools (used in the field reviews) that may assist in the adaptation
process and field testing (annex 2), and a summary of recommendations from the field reviews
(annex 3).
2. About the MNH Counselling Handbook

2.1 Background
This generic MNH Counselling Handbook is designed to support SAs in developing effective
counselling and communication skills in maternal and newborn health. It can be used in
conjunction with the PCPNC, but also on its own, as fundamental information from the PCPNC has
been integrated into the Handbook, including Section M, Information and Counselling sheets,
which summarize the key information to share with women and their families during pregnancy,
labour and birth, and in the postnatal and post-abortion periods.
The nature of the MNH Counselling Handbook is open and flexible, with a strong emphasis on
skills building. In the past, SAs have frequently focused on one-way provision of information rather
than two-way shared dialogue. The main mandate of this Handbook is to provide key counselling
skills to the SAs so they can assist women and their families to make informed decisions to
improve maternal and newborn health. Women are more likely to improve their health status if they
have a full understanding and ownership in the decision-making process (Portela & Santarelli,
2003).
The MNH Counselling Handbook is chiefly designed to be used by groups of SAs with the help of a
facilitator. Ideally, the facilitator should be someone with a counselling background who can guide
and motivate the SAs as they work through the Handbook. It can also be used by individuals who
can get together with other SAs for discussions and activities where needed. It relies on a self-
directed learning approach, allowing SAs to work at their own pace, drawing on their past
counselling experience. The way it is used will be determined by each country’s context, and the
SAs’ preference.
2.2 Development
The MNH Counselling Handbook was developed through a participatory process that incorporated
the views and expertise of a wide number of international stakeholders, both in developed and
developing countries. It has been field tested with the intended users in three countries2
2The content was also reviewed with community midwives in Malawi during an early stage of development.

(Indonesia, the Philippines, and Sudan) through a review process that included group discussions,
in-depth interviews, observation techniques (groups of SAs working through specific topic
sessions), and questionnaires. The findings from these methods were compiled and presented at a
workshop which took place in each country at the end of the review process, to generate a
consensus among SAs and programme managers for the recommended changes. The findings
from the different field reviews were then discussed by an international expert panel in a meeting at
WHO Headquarters in Geneva. Maternal and newborn health specialists were asked to review the
Handbook and provide their comments which were also reviewed in the above-mentioned meeting.
The expert group provided guidance as to revisions and amendments to be made. Finally, the
MNH Counselling Handbook was edited for comprehension, technical accuracy, grammar and
punctuation.
2.3 Content
The MNH Counselling Handbook is divided into three main sections. Part 1 is an introduction which
describes the aims and objectives and the general layout of the Handbook. Part 2 describes the
counselling process and outlines the six key steps to effective counselling. It explores the
counselling context and factors that influence this context including the socio-economic, gender,
and cultural environment. A series of guiding principles is introduced and specific counselling skills
are outlined. Part 3 focuses on different maternal and newborn health topics which are outlined in
Box 2 as below.
The MNH Counselling Handbook contains specific aims and objectives for each session, clearly
outlining the skills that will be developed and corresponding learning outcomes. Practical activities
have been designed to encourage reflection, provoke discussions, build skills and ensure the local
relevance of information. The information generated through these activities may prove valuable for
SAs during their counselling sessions. For example, one activity asks the participants to identify
local beliefs and practices related to pregnancy and childbirth, and then categorize these practices
into helpful, harmless, or harmful to the woman and her newborn. This list can guide future
discussions with women and their families. Another activity aims to improve the physical
counselling environment and asks the SAs to examine their health facilities from a woman’s
perspective and make concrete changes to improve the overall atmosphere. There is a review at
the end of each session to ensure the SAs have understood the key points before they progress to
subsequent sessions.
Box 2: MNH Counselling Handbook's Topics
Box 2 MNH Counselling Handbook’s Topics

Session 6 General care in the home during pregnancy
Session 7 Birth and emergency planning
Session 8 Danger signs in pregnancy
Session 9 Post-abortion care
Session 10 Support during labour and childbirth
Session 11 Postnatal care of the mother and newborn
Session 12 Family planning counselling
Session 13 Breastfeeding
Session 14 Women with HIV/AIDS
Session 15 Death and bereavement
Session 16 Women and violence
Session 17 Linking with the community

Figure 1 illustrates the core counselling concepts outlined in the MNH Counselling Handbook. At
the beginning of each topic session, the image is repeated, with the relevant counselling
skills/concepts highlighted specifically for each particular session. These are not mutually exclusive
and an SA can work through the topics systematically or simply choose topics or counselling skills
that she/he needs to strengthen. The Handbook is designed to build on the SAs’ existing
knowledge and strengthen their counselling skills.
Figure 1. Schematic Overview of the Counselling Process
2.4 Key Principles

The MNH Counselling Handbook promotes a participatory, interactive approach and focuses on
counselling methods that accentuate dual communication, interaction and dialogue. Counselling
principles including self-reflection, empathy and respect, and shared problem-solving are
emphasized. The value of forming an alliance with the pregnant woman and her family (or the
community at large) is discussed and ways of facilitating a two-way discussion through open
questioning and active listening are explored. The MNH Counselling Handbook addresses the
importance of:
o the woman making health decisions in partnership with the SA

o the woman’s wishes and choices being respected
o the SA helping to find solutions and generate alternatives to suit the woman’s needs
o the SA respecting the woman, ensuring confidentiality, and demonstrating a non-judgemental
attitude.

2.5 Intended Users
The MNH Counselling Handbook is primarily designed for use by Skilled Attendants3. A universal
definition of a “skilled” attendant is difficult to operationalize, as levels of education and
competency/skills vary from country to country. During the field reviews, it was discovered that the
educational status of SAs varied from practitioners with Master’s Degrees, to those with primary
levels of education assisting in births following a six-month training course. While it is recognized
that most countries are working towards the definition stated below, the MNH Counselling
Handbook has been designed using simple language, and aims to cover a broad audience, even
those with lower levels of education. The successful use of the MNH Counselling Handbook will
obviously depend on the overall literacy and educational levels of the SAs, and their current
standards of practice.
The definition stated below has been used for the purpose of the MNH Counselling Handbook and
adaptation guide:
The term skilled attendant is defined as “an accredited health professional - such as a midwife,
doctor or nurse - who has been educated and trained to proficiency in the skills necessary to
manage normal (uncomplicated) pregnancies, childbirth and the immediate postnatal period, and in
the identification, management and referral of complications in women and newborn.” (WHO et al,
2004)
If a different definition of SA is used by certain countries, or the MNH Counselling Handbook is to

be used in SA pre-service training, or for a different type of health worker, adaptation issues will
vary accordingly. Where this was the case in the field reviews, some programmes suggested using
a facilitated approach with role-plays and taped versions of the MNH Counselling Handbook as a
way to ensure that those health workers with lower reading levels could fully understand its
contents.
3. Adaptation Process
The next session suggests a methodology for the adaptation process. The framework has been
drawn from a variety of WHO adaptation guides (WHO, 2007; WHO, 2005; Church K, 2006), data
from field reviews, and comments from the WHO expert panel.
3.1 Assessing the Need to Adapt

The MNH Counselling Handbook has been designed as a generic document. The decision on
whether to adapt the Handbook and the degree of adaptation required will be dependent on each
country’s needs and circumstances. The purpose of this document is to provide a suggested
framework for programme managers to analyse the MNH Counselling Handbook, helping them to
change the global document into a locally acceptable, culturally sensitive version to suit their
country context. The team is encouraged to consider national norms, modifications to the PCPNC,
language and dialect issues, and local terms related to maternal and newborn care.
3 The MNH Counselling Handbook may be used in pre-service or in-service training.

The generic MNH Counselling Handbook is available on-line and for a free download access on
http://www.who.int/maternal_child_adolescent/documents/9789241547628/en/
For a hard copy of the MNH Counselling Handbook write to:
Department of Maternal, Newborn, Child and Adolescent Health (MCA)

World Health Organization
20 Avenue Appia
1211 Geneva 27
Switzerland
Tel.: +41 22 791 3281

Fax: +41 22 791 4853
E-mail: mncah@who.int
The software used for the MNH Counselling Handbook is ADOBE InDesign CS 2 and CS 3. The
original document has been printed in colour.
3.2 Process of Adaptation

Figure 2 below outlines a flow diagram with a suggested process to facilitate the adaptation of the
MNH Counselling Handbook. Each entry is explained below in more detail.
Figure 2. Flow Diagram: Suggested Adaptation Process
Appoint Adaptation Committee
Develop Terms of Reference
Adapt Handbook
Translate Handbook
Identify Barriers & Motivators to use
Production, Distribution & Dissemination
Is it aligned with National Policies?

Are new topics needed?
Are concepts clear? Training & Supervision
Is there a consensus for adaptation?
Field Test Handbook (with SAs and others) Monitoring & Evaluation
Amend where necessary Amendments

3.2.1 Appoint an Adaptation Committee
It is important to identify a group of key stakeholders and appoint a committee or an adaptation
taskforce. If a committee has already been formed to adapt the PCPNC, a small subgroup from this
committee could be appointed to ensure that the changes to the PCPNC are taken into account
when reviewing the MNH Counselling Handbook. If a committee does not exist, a variety of
members could be invited to join the committee, including representatives from the Ministry of
Health, non-governmental organizations, professional associations (including different cadres of
nurses, midwives, doctors and obstetricians), health managers of private and government
institutions, district health officers, other key ministries, and departments (e.g. social work,
counselling, community services, media, communication, health education etc.), local opinion
leaders, women’s groups, religious groups and youth groups. The size of the adaptation committee
will depend on each country’s needs, but experience has shown that large groups for these tasks
are often less functional. You may wish to include a larger group to review and provide comments
but designate a smaller adaptation committee charged with making final decisions; you may wish
to organize a number of different working/sub-groups that can provide technical input. For
example, one sub-group could provide technical input if a new maternal health or newborn health
session needs to be developed, or they could ensure that the MNH Counselling Handbook is
aligned with national policies. Another sub-group may be responsible for the production and
dissemination of the MNH Counselling Handbook, and the third sub-group could organize training,
supervision and evaluation strategies.
3.2.2 Develop the Terms of Reference

Once an adaptation committee and/or technical sub-groups have been appointed, a working brief
or terms of reference for the group could be developed. This will determine how the group will
function. Issues to consider include the appointment of a chair, someone to take minutes, and
perhaps a principle coordinator who could review the document in detail before the larger group
meets. Goals, specific objectives and a timeline should be drawn up, and activities outlined.
3.2.3 Review the MNH Counselling Handbook4

Before reviewing the MNH Counselling Handbook, it is essential to agree upon the intended users.
As previously mentioned, a clear definition of the SAs’ literacy levels, educational background and
skills level should be established. This will affect a number of factors as you go through the MNH
Counselling Handbook. For example:
• Are there any concepts that are either too difficult or self-evident for the intended group of
users?
• Even in English speaking countries, there may be language issues. In a non-English
speaking country, at what moment in the process does the MNH Counselling Handbook
need to be translated and in how many languages or dialects, depending on the context?
In any language consider if the language is clear for the SAs? Are national/local terms for
MNH used and appropriate?
• Are the images acceptable? Do they accurately portray the reality?
• Are the technical aspects appropriate to the SAs’ skill level?
4Note - We have placed "Translation" after "Adaptation" in the flow diagram above. However, translation may need to occur
prior to review by the Adaptation committee. See section 4. below

• Does the MNH Counselling Handbook adhere to national policies, guidelines and
protocols?
• Do other MNH counselling guides exist? If so, is there new information in this MNH
Counselling Handbook relevant to your setting? If other counselling guides exist, it would
be beneficial to review them and decide which one best addresses the SAs’ MNH needs or
if different content from the different guides need to be pulled together.
You may wish to determine who would be best suited to review the different sessions of the MNH
Counselling Handbook and could consider dividing sessions up to ensure the individuals with the
most expertise review their areas of speciality. Examples of speciality topics include family
planning (FP) counselling, post-abortion care, breastfeeding, violence against women, and
HIV/AIDS.
It is also important to ensure your country’s relevant existing Reproductive Health (RH) and MNH
manuals, policies and guidelines are readily accessible for reference. A copy of the WHO PCPNC
would be helpful.
3.2.4 Adaptation
Once the MNH Counselling Handbook has been reviewed by the committee and/or working sub-
groups, a decision will be made on whether it needs to be adapted, and if so, which priority areas
require attention. The following list of questions could be considered to guide you as you adapt the
document:
• What changes need to be made to ensure that the MNH Counselling Handbook
adheres to national policies, guidelines and protocols? Or what national policies,
guidelines and protocols need to be reviewed based on evidence from the PCPNC?
• Are there any RH or MNH issues that need to be addressed? For example, highly
prevalent issues like malaria or female genital mutilation, that have not been
addressed in the generic MNH Counselling Handbook.
• Are there any issues that are not relevant to your country or programme context that
you wish to remove?
• Are there any legal issues that need to be addressed that are not currently
considered?
• Are there any human, sexual and reproductive rights issues that have not been
adequately addressed?
• Is the technical information relevant to your specific health care setting?
• Are there any specific cultural beliefs or traditions which need to be addressed?
• Are the changes you plan to make based on sound evidence?
• Is the language clear and easy to understand?
• Do the illustrations adequately portray the key messages? Are there enough images?
Too many images? Do they reflect the customs and culture?
These issues will be discussed in more detail under section 5 of this guide.

3.2.5 Align with National Policies
Each country will have its own maternal and newborn health policies, procedures, protocols and
standards. It is important that the information contained in the MNH Counselling Handbook is
consistent with these policies. However, if there is a disparity, the adaptation committee should
consider if the national policy has been based on the latest body of evidence. When reviewing the
MNH Counselling Handbook, pay special attention to the topic sessions, screening them for
policies that are not familiar or endorsed in your environment. You may wish to appoint a maternal
and newborn health expert from the working sub-group to concentrate on this task. Further specific
details of areas of potential discrepancy will be discussed in section 5.7.
4. Translation
Most countries will need to translate the MNH Counselling Handbook into their language. In
countries where different dialects are spoken, it may need to be translated into several languages.
This is a very important part of the adaptation process and can prove quite difficult. The WHO field
reviews in Sudan and Indonesia exposed fairly substantial problems related to translation issues.
For example, the divergent educational background of the SAs meant that while certain higher
educated SAs (obstetricians, physicians, and registered nurses, to name a few) fully understood
the English version, for less well educated, rural SAs, many terms were found to be confusing and
misunderstood. It is important to give enough time, thought, and resources to this vital task. WHO
recommends translations be done by bilingual experienced MNH experts, preferably with sound
local knowledge. A few tips are listed in Box 3 to help produce a high-quality translation.
Box 3 Translation Tips
• It is important to keep the essence /integrity of the MNH Counselling Handbook.

• Use exact words rather than summaries or interpretations.
• Keep it simple and clear.
• Do not omit ideas and concepts because they are hard to translate.
• Translate ideas even if they seem culturally unfamiliar.
• Develop a glossary of key medical and counselling terms that is consistent so that words or phrases
can be repeated throughout the MNH Counselling Handbook to help the SAs reinforce ideas.
• “Back translation” may be required. This was found to be an important part of the translation process in
the field reviews. In other words, once the document is translated into a second language, ask a third
bilingual party (not the translator) to re-translate the document into English, and then compare it with
the original English version. It would be helpful to provide the glossary of key medical/counselling
terms to ensure internal consistency.
5. Suggested Adaptations
5.1 Links with PCPNC

The technical information in the MNH Counselling Handbook has been principally drawn from the
PCPNC. It is likely much of this information has already been approved and/or adapted with the
introduction of the PCPNC into your country programmes. Table 1 summarizes areas of the
PCPNC that correlate with the adaptation guide and the MNH Counselling Handbook.

Table 1. PCPNC Links to Adaptation Guide & MNH Counselling Handbook
Content MNH PCPNC Adaptation

Counselling Section Guide
Handbook Page nos.
Sessions
Managing pregnant adolescents Session 2 H3 Pages 21 & 22
• Helping adolescents consider
options
Emotional support for women with Session 2 H2 Page 21
special needs
Supporting women living with violence Session 16 H4 Page 16
Community links & co-ordination with Session 17 I12
health care providers/TBAs
HIV/AIDS key information Session 14 G2 Page 19
• HIV care G3
MTCT Sessions 13 & 14 G6 Page 18
• Counselling on feeding choices G7
• Replacement feeding G8
Newborn care Session 11 J10
Breastfeeding Session 13 K Page 18
• Assessing breastfeeding J4
• Counselling on breastfeeding K2
• Alternative feeding methods K5
• Information/counselling sheets M
General care during pregnancy Session 6 M2 Page 17
Preparing Birth and Emergency plans Session 7 M3 Page 17
Care for mother after birth Session 11 M4
Care for mother post abortion Session 9 M5 Page 16
• Advice and counsel/self-care& B21
support B21
• Family planning Session 12 Page 18
Care for baby post birth Session 11 M6
Preventive measures/additional Session 6 F
treatment F3
• Iron and folic acid Session 11 F4 Page 20
• Malaria prevention
Antenatal care C
• Assessment Session 8 C2-C6 Page 17
• Signs and symptoms C7-11
• Developing birth & emergency Session 7 C14-C15 Page 17
plans
• Advice on danger signs Session 8 C15
• Family planning Session 12 C16 Page 18
Childbirth: labour, delivery & postpartum Session 10 & 11 D
care
• Supportive care in labour Session 10 D6-D7 Page 13
• Birth companion D7 Page 13
• Problems immediately Session 11 D22-D25
postpartum
• Home delivery Session 7 & 10

Content MNH PCPNC Adaptation
Counselling Section Guide
Handbook Page nos.
Sessions
Postnatal care Session 11 &13 E
Clean home delivery M8-M9

• Home delivery by skilled Session 7 & 10 D29
attendant
Emergency treatments for the woman Session 8 & B
• Bleeding Session 7 B10-12
• Pre-eclampsia/Eclampsia B13-14
• Infection B15
• Malaria B16 Pages 20
• Urgent referrals B17
5.2 Considerations for Adaptation

Table 2 below, summarizes considerations for adaptation and provides issues for the adaptation
committee to focus on. This is by no means an exclusive list, and the taskforce may come up with
additional issues to consider. Annex 3 provides recommendations from the field reviews in
Indonesia, the Philippines and Sudan. Note when making modifications, it is important to maintain
the internal consistency of the MNH Counselling Handbook, so if the team makes changes in one
session, for example in family planning methods or breastfeeding techniques, related points may
be discussed in different sessions, and they should also be adapted accordingly.
The main objective of the adaptation process is to ensure that the MNH Counselling Handbook is
relevant, applicable and understandable to SAs or the intended users, and reflects the national
policies, culture and maternal and newborn health context.
Table 2 Summary Table: Considerations for Adaptation
Issue Considerations
Cultural Considerations Are cultural issues addressed sensitively & appropriately?
Illustrations Are images appropriate? Clear?
Local Terminology & Concepts Are concepts understandable? Words familiar?
Legal, Human & Reproductive Rights Are there legal issues that clash with current policy?
Are there reproductive rights issues not addressed?
Are there elements which can help you advocate for
improved women’s rights?
Consistency with National Protocols Are all procedures in line with national policy?
Priority MNH issues not addressed Have all prevalent MNH issues been covered? Are
• Female Genital Mutilation issues that are not relevant included? (For example,
• Obstetric Fistulae malaria in non-malaria areas?)
• Malaria

5.3 Cultural Considerations
In many societies cultural beliefs and practices play an important role in pregnancy, childbirth and
the post natal period and therefore need to be carefully considered throughout the MNH
Counselling Handbook. This section covers some cultural issues that arose from the field reviews,
but there may be additional issues relevant to your own countries’ belief systems that the
adaptation committee identifies or discovers as they conduct initial reviews.
As it stands, the MNH Counselling Handbook provides ways to help SAs explore local customs and
cultures in order to assist them to communicate effectively and provide quality care to women,
families and communities. She/he can support those beliefs and practices that are helpful or
neutral, such as exclusive breastfeeding and burial of the placenta respectively, and deter those
deemed harmful, through a series of activities and interactive discussions with the broader
community. In this way, local customs are respected except where the practice causes harm. One
example of a harmful practice is the custom whereby male partners are encouraged to engage in
sexual relations outside the marriage or primary relationship, placing the pregnant woman at risk of
sexually transmitted infections. Other examples of harmful practices include placing cow dung on
the baby’s umbilical cord which can cause infections and neonatal tetanus, giving the newborn
other fluids (like honey) instead of exclusive breast milk, and rituals which delay accessing
emergency care when danger signs are noted. In these cases the SAs could have a dialogue with
the community and key decision-makers or a discussion could be held with the working group to
address harmful practices, guided by a trained facilitator, in order to reach an agreement on how
best to address the local custom, while ensuring that women or babies are not placed at risk.
Another issue for the team to consider is the use of the word “partner” throughout the MNH
Counselling Handbook, rather than “husband”. (This word was chosen in order to take into account
couples in union or single pregnant women). Some countries in the field reviews preferred to use
“husband” and if this is the case, this would need to be adjusted throughout.
5.3.1 Counselling Skills (Session 3)

Different cultures have different ways of communicating effectively. For example, it may be
appropriate in one country to maintain eye contact, smile and nod to show that you are empathetic
and actively listening; however this behaviour may be inappropriate in another culture. Page 33
contains a list of active listening behaviours. The team can review this list, and ensure culturally
appropriate actions are included.
5.3.2 Factors influencing the Counselling Session (Session 4)

This session was the focus of considerable discussion during the field reviews. The concept of
gender, which was initially not well understood, has been addressed in the generic version of the
MNH Counselling Handbook. The boxes on pages 49 and 50 can be adapted to suit the local
context and the national maternal mortality ratio could be included. Are there examples of gender
roles in your community that you could also incorporate? The team may wish to examine gender
inequalities relevant to their national context. National statistics could reveal important
discrepancies: including the gender gap in education levels between men and women, differences
between male and female infant mortality rates, the number of female versus male-headed
households, who acts as the major decision-maker in the household, and the status of women in
society.

Self-reflection as an activity was another concept that many SAs during the field reviews found
hard to understand. When field testing the MNH Counselling Handbook in your country, this is an
area that might be worth better explaining.
Counselling on issues of sexuality (page 56 and addressed in other parts of the Handbook as well)
and the section that explores perceptions about women’s bodies (page 57) are both areas that may
need to be reviewed. The field reviews have shown this to be a challenging area and one in which
local adaptation is particularly important. Counselling around this area will be guided by local
custom, religion and practices (including sexual practices) and this will ensure that the counselling
is acceptable to the community. This could mean that some of the suggestions on counselling
around sexual issues that are included in the generic MNH Counselling Handbook may not be
considered acceptable to the community, in which case alternatives can be suggested by the
group. Certain cultures may not be used to openly addressing sexuality, and may be reluctant to
include these topics in the newly adapted MNH Counselling Handbook; however they are
fundamental issues and as such may need to be discussed by the adaptation team before they
decide how to manage them.
It will also be beneficial to include local terms and phrases for sexual issues which are commonly
used and acceptable to the community. To gain information about local sexual practices the
working group may decide to divide into male and female discussion groups.
Results from the field tests in Sudan and Indonesia indicate that some SAs did not wish to include
the sentences that discuss FP methods for unmarried women or adolescents. Teenage
pregnancies contribute to maternal mortality and morbidity and it is therefore not recommended to
delete these sentences, but this remains an important issue for the adaptation team to resolve.
There is the scope in this session to add more information about religious beliefs and perspectives
as per local belief systems.
5.3.3 Support during Labour and Childbirth (Session 10)

Some countries do not allow the presence of a companion of the woman's choice during labour
and childbirth (also referred to as companions in childbirth or social support during labour and
childbirth). This may be due to a variety of reasons (cultural beliefs, policy barriers, providers'
attitudes, or limited space in birthing rooms, for example). Research shows that a woman with
support during labour – a birth companion of her choice rather than a staff member – has a shorter
labour, is more likely to have a spontaneous vaginal delivery, is less likely to need analgesia, is
less likely to need medical intervention, and is less likely to be dissatisfied with her birth experience
(Hodnett et al, 2013). Social support during childbirth is likely to lead to SAs paying more attention
to the labouring woman’s wishes, and to more information being provided about the labouring
process (PANOS, 2001). There may be an opportunity to advocate for birth companions if it is
currently not the common practice. Advocacy for a supportive policy environment to encourage
birth companions during labour is necessary. This involves not only improving SAs’ skills and
knowledge levels, but also ensuring space in the birthing rooms, increasing the involvement of
men, or other family or community members during childbirth, birth and emergency planning, with
the selection of a clearly defined companion prior to labour. Another important policy implication
involves improving the collaboration with other care providers, including Traditional Birth
Attendants (TBAs) (WHO, 2003).

5.3.4 Death and Bereavement (Session15)
This session was very well received by all SAs in the field reviews, as the information was new to
them and relevant to their practice. Some felt there should be more information on religion and
there is the scope in the adaptation process to incorporate different religious perspectives. The list
of practical tasks to perform when someone dies (page 188) can be reconsidered and specific
rituals significant to local culture could be added. This session focuses on burial only, but in
countries where cremation is the norm, practical advice and information can be added relating
specifically to cremation (page 188).
5.4 Illustrations
The MNH Counselling Handbook’s illustrations were intended to reflect different country contexts
and include a cross-section of nationalities and cultures. A selection of different scenarios is
presented in both rural and urban settings. The team may wish to add more illustrations. Feedback
from the field reviews indicated that the concepts conveyed by the images were understood by
most of the participants. Nevertheless, each programme should carefully review and field test the
images to ensure their comprehensibility, acceptance by intended users, and applicability to their
local context. In general, background scenes can be changed to more realistically illustrate the
settings where the MNH Counselling Handbook will be used.
Several images contain signs written in English to help convey key concepts. If the MNH
Counselling Handbook is maintained in English, the words in the signs should be studied and
adapted if necessary to make sure they are locally understood. If it is translated, the signs should
also be translated. Listed below are the images with English signs:
• Session 2, page 21: translate text bubble
• Session 5, page 60 : translate sign
• Session 14, page 163, Cover: field test image and ensure availability of Voluntary Testing
and Counselling services
• Session 15, page 183, Cover: translate writing on tombstone
• Session 17, page 215: translate sign
Certain images in particular are noted below as they may require specific modifications to
reflect the national or local context. For example:
• Session 3, page 33: is eye contact appropriate in your country?
• Session 6, page 73, Cover: may wish to adapt food to those available locally.
• Session 7, page 89: if the national programme has a birthing card, it could be inserted
here.
• Session 12, page 145: should reflect all FP methods available in the country.
• Session 15, page 183, Cover: may want to ensure an appropriate burial (or cremation) as
per country’s religious beliefs and practices.
If a new section has been developed, additional images can be inserted to break up the text and
help the reader understand key messages. A local artist or graphic designer may be hired to
develop the illustrations, which should then be field tested.
During the field reviews, many of the participants expressed an interest in having coloured
illustrations, and a glossy, waterproof cover. This will be much more expensive to produce and will

depend on the allocated budget for this project. The generic MNH Counselling Handbook was
produced using four colours.
5.5 Local Terminology and Concepts

The MNH Counselling Handbook, designed to use simple and clear language, has been developed
with input from primary stakeholders in the field. Texts were further simplified after the field review
process as many participants found the sentences were too long and some of the words and
concepts new and confusing. Many concepts have now been explained in more detail, and a
glossary of key terms has been added as an Annex. The adaptation team may wish to further
simplify the vocabulary and medical terms, depending on the educational level of those health
workers intending to use it in the country. The translation of medical and counselling terms can
also prove problematic. As previously discussed, it is important to develop a glossary of approved
(and field-tested) translations to use consistently throughout the MNH Counselling Handbook.
Table 3 below lists some of the terminology and concepts that proved to be difficult to understand,
and may need to be adapted and/or translated with caution.
Table 3 Potential Language Barriers
Medical terms Key concepts Other words

Morbidity Gender Socio-economic
Mortality Empowerment Objectives
Discordant Self-reflection Context
Miscarriage Interaction Confidentiality
Prevalence Alliance Facilitation
Epidemic Empathy Implications
Postnatal blues Disclosure Motivators
Convulsions Self-esteem Deceased
Blurred vision Violation Taboos
Oedema
Vaginal discharge
Mother-to-Child Transmission
Lochia
Episiotomy
5.6 Legal, Human and Reproductive Rights

What are the policy and legal issues relevant to maternal and newborn health in your country? This
is particularly pertinent to the sessions discussing domestic violence, family planning and abortion.
It is important to advocate for change to advance the rights of women even if such policies are not
yet in place. WHO has developed a Health and Human Rights Assessment Framework and a tool
Using Human Rights to advance Sexual Reproductive Health; strengthening laws, regulations and
policies to help countries analyse the policy environment from a maternal and newborn health
perspective and this may be a valuable means of assessing women’s and newborns’ health rights
in your region (WHO, 2010).

5.6.1 Post-Abortion Care (Session 9)
22 million unsafe abortions occur globally with an estimated death of 47 000 women and
disabilities for an additional 5 million women (Ahman & Shah, 2011). The adaptation committee
should consider the following when reviewing: Is abortion legal in the country? What kind of
abortion and post-abortion services are provided? Do women have access to emergency
contraception? These issues may be sensitive in some countries. Session 9 on Post-Abortion care
is designed for both miscarriages and elective abortion/termination. You may wish to adapt this
section to suit your local context. It is an important advocacy point as abortion rates were found to
be no lower (overall) in regions where abortion is illegal than where it is legal (Sedgh, S. et al.,
2007). Abortion and the consequences of unsafe abortion contribute to maternal mortality and
should be addressed in the future as an important strategy to safeguard women's reproductive
rights, reduce maternal deaths and improve women's health.
5.6.2 Women and Violence (Session 16)

Domestic violence, the most common type of gender-based violence, affects many women
worldwide. Recent global prevalence figures indicate that 35% of women worldwide have
experienced either intimate partner violence or non-partner sexual violence in their lifetime (WHO,
2013). In some cultures domestic violence may increase during pregnancy. Yet, it is often a
difficult and sensitive topic for health workers to approach and many SAs may feel they do not
have the confidence, skills or training to tackle this delicate issue. There may therefore be a need
to provide a training course for SAs in specific counselling on violence, if this is a prevalent
problem in your area.
This session on women and violence includes an activity (Table on page 199 that explores myths
surrounding domestic violence). There is an opportunity for the team to add in any local beliefs
relevant to their country’s setting to contextualize this activity and make it more relevant to the
national population. Laws and policies designed to protect the fundamental human and
reproductive rights of women may not yet be in place. After analysing session 16, are there any
ways you can advocate to improve women’s human and reproductive rights? This session (as with
the HIV/AIDS session) is meant to be an introduction to familiarize SAs with the problem and
provide some basic counselling principles. However this session does not intend to be exhaustive
and provide all the necessary skills. It is important that if violence is prevalent in your area, the
programme makes contact with other organizations specializing in violence against women, who
can provide further support to the women in need.
5.7 Consistency with National Protocols and Guidelines

Are there any important policies or protocols that have been omitted from the MNH Counselling
Handbook? Are there national RH or MNH policies that are not consistent with the MNH
Counselling Handbook? If so, are they based on the latest research and sound evidence? For
technical issues the team can refer to their national guidelines and policies, and in their absence
refer to WHO guidelines as outlined in the PCPNC.

5.7.1 Counselling Paradigms (Sessions 2-5)
Sessions 2 through 5 outline the key counselling principles the SA will learn as he/she works
through the MNH Counselling Handbook. It is important that the concepts are well understood. As
the adaptation team reviews the counselling paradigms, they can consider how the proposed
concepts differ from what is currently in use. Are there any additional counselling concepts the
team would like to add into sessions 2 and 3?
The counselling context schematic diagram (page 4 in this document and Session 2 in the MNH
Counselling Handbook) is introduced in session 2, and then reappears at the beginning of each
session thereafter, highlighting different principles and skills for each session. It is fundamental to
the MNH Counselling Handbook, and therefore essential that it is understood and accurately
adapted if needed. The diagram could be reviewed by experts on the adaptation team and then
included during the field testing with different groups of SAs.
Session 3 contains a diagram that demonstrates how each guiding principle feeds into the different
counselling skills. During field reviews, some SAs in rural areas found the arrows confusing as they
were not used to this type of drawing. Conversely, the more educated SAs from urban areas were
able to understand the diagram and found it very helpful. This image may need to be reviewed and
also carefully field tested.
5.7.2 General Care (Session 6)

The WHO recommendations on care for the woman in the home during pregnancy could be
adapted to suit the national context. Are there any specific Antenatal care protocols in your country
that have not been included here? The adaptation team could consider brainstorming with
community groups (in Activity 1) to ensure all important aspects of general care for the pregnant
woman and her family are met. One way to customize this session is to develop a list of locally
available and affordable foods that meet the nutritional requirements of pregnant women.
This session does not include any malarial prophylaxis. You could consider adding local
recommendations if you live in an endemic malarial zone, for example a sentence on the
importance of taking malaria prophylaxis during pregnancy as per local/national guidelines, or the
benefits (to the woman and her baby) of sleeping under an impregnated bednet. (For more details,
refer to the malaria section in this document, 5.8.3).
5.7.3 Birth and Emergency Planning (Session 7)

Are birth and emergency cards already established in the country? The team may wish to check
the sample card in the session to ensure all relevant local information is included and make
amendments as necessary. The questions for birth and emergency planning on, or the sample
card, can be replaced with a scanned copy of the national birth and emergency planning card.
Community transport plans can play an important role in improving women’s access to skilled care
during pregnancy and birth, and for the mother and baby in the postnatal period. Transport plans
are briefly discussed but you may have successful examples from your country or other countries
in your region that the adaptation team could consider introducing here.

5.7.4 Family Planning Counselling (Session 12)
Some family planning (FP) methods mentioned in the text or the table may not be available in your
country, others may be about to be introduced, or some methods phased out, depending on
availability, and national or local protocols. The team should check to make sure the methods
mentioned are available nationally, and at the first level of care.
This session is not designed to provide all the FP information but highlights the basic and essential
information for counselling women and their partners. For additional detailed FP information, refer
to the WHO’s “Evidence-based guidance: Decision-making tool for family planning clients and
providers” on the following link:
http://www.who.int/reproductivehealth/publications/family_planning/9241593229index/en/
For both FP or for counselling a woman following an abortion, the MNH Counselling Handbook
talks about providing emergency contraception to women to prevent future unwanted pregnancies.
Is this available in your country? If not, consider advocating for it as an important strategy for
reducing maternal morbidity and mortality related to unwanted pregnancies and abortions.
Providing adolescents with FP is often a topic of debate and discussion. It is an important concern
however, as teenage pregnancies are common, largely preventable, and contribute to maternal
morbidity and mortality. For additional information on the specific skills required to counsel
adolescents, refer to section 5.8.4 below.
5.7.5 Breastfeeding (Session 13)

Breastfeeding materials may be available and you may wish to engage some national
breastfeeding groups to support the review of this session and ensure its link with existing
materials, trainings and support. This session is intended to provide basic information as SAs
should refer women to those SAs more trained in infant feeding, if available. The following link
http://www.who.int/maternal_child_adolescent/documents/who_cdr_93_3/en/ will provide additional
information and tools available on breastfeeding.
Prevention of Mother-to-child Transmission (PMTCT) of HIV/AIDS is also addressed in this session

and is an important public health concern in many developing countries. Each country will have its
own PMTCT strategies in place which can be drawn upon and included in this section. The
Handbook covers basic information and health workers are encouraged to seek additional training
if in their area more experienced counsellors are not available or if HIV is prevalent. The following
link http://www.who.int/hiv/pub/vct/tc/en/index.html can also direct you to additional tools and
training available from WHO.

5.7.6 Women with HIV/AIDS (Session 14)
Although the guidance in the PCPNC assumes a high HIV/AIDS prevalence area, the information
provided in this session of the MNH Counselling Handbook is designed merely as an introduction.
This section is intended to provide basic information as SAs should refer to those more trained if
available. Additional information and tools available are provided in the following link
http://www.who.int/child_adolescent_health/documents/9241592494/en/index.html. The team
should determine whether the high prevalence rates apply to their context, and if so, links can be
made with other support services available in the region, such as testing and counselling services,
or People Living Positively with AIDS (PLPWA) groups. There are references to Antiretroviral
(ARVs) medications and testing in this session of the MNH Counselling Handbook, and the team
should ensure that these services are available and accessible, or adapt the text accordingly.
Counselling and the topic information surrounding these issues may need to be adapted with
assistance from local HIV/AIDS experts in the country, and additional training for counselling
women with HIV/AIDS may need to be provided.
If a low HIV/AIDS prevalence exists, more emphasis could be placed on prevention and the text
adapted according to local policies for low transmission areas, with the help of local RH/HIV/AIDS
experts.
5.8 Priority Maternal and Newborn Health issues not addressed

Does the MNH Counselling Handbook currently cover the main maternal and newborn health
issues related to maternal and newborn care that are prevalent in the country? Each country will be
aware of their key maternal and newborn health problems, through a detailed RH situation analysis
and data from health surveys. Existing qualitative and quantitative studies may also provide
information concerning care in the home, care-seeking behaviour, and the community's perception
of the quality of the MNH services. This information can also help reveal counselling and
communication gaps. These issues can be compiled and then compared with the topics covered in
the MNH Counselling Handbook. Does the Handbook adequately cover the main
maternal/newborn and counselling issues relevant to your country? The following text provides a
few examples of additional priority problems, prevalent in a number of countries, which, if
applicable, could be considered for inclusion.
5.8.1 Female Genital Mutilation (FGM)

More than 125 million girls and women alive today have been cut in the 29 countries in Africa and
Middle East where FGM is concentrated with more than 3 million girls in Africa estimated to be at
risk for FGM annually (UNICEF, 2013). A WHO prospective study on FGM conducted in six
African countries shows that women with FGM are much more likely to experience negative
outcomes including: increased rates of C-section, episiotomies, postpartum haemorrhage, urinary
tract infections, and infants who require resuscitation. The study findings show women with FGM
are more likely to require longer hospital stays and that the obstetric risk increases with the
magnitude of FGM (WHO, 2006). This has important implications for the adaptation teams in terms
of planning for antenatal care, birth and emergency preparedness, and immediate post-natal care
for the mother and newborn.
Field reviews of the Handbook in some countries exposed FGM as a priority RH issue, and the
participants in Sudan expressed strong interest in adding a special session devoted to this practice
as there are many unique physical and psychological issues to consider. It was felt that the session

should include a definition of FGM (outlining the different types), and the main disadvantages that
occur such as infection, bleeding, obstetric fistulae (OF) (see section 5.8.2), and disease
transmission. Important counselling issues were discussed including the problems surrounding
SAs conducting a physical examination and catheterising women who have undergone FGM, the
difficulties pregnant women experience with first intercourse and labour, and their violation of
human and reproductive rights. Pregnancy may also be a good time to talk to women and their
families about FGM and sensitize them to consider the harms to the girl-child. In addition to a
separate session on FGM, it is a theme that may need to be added to Session 17 for discussion
with the broader community.
Culturally sensitive activities in the FGM session could be designed to allow discussion on how to
replace harmful practices with less harmful or neutral ones. For example, a “coming of age”
ceremony could still take place but beads could be given instead of the customary cutting
ceremony or if certain songs are meaningful, the tunes could be maintained while the words could
be changed. Gatekeepers here play a vital role, especially the grandmothers, elderly women, and
husbands, so it would be advisable to include other individuals in the counselling sessions to
ensure the harmful behaviour is modified. (See Annex 3 for details of FGM sources and issues.)
The following WHO links provide additional information on FGM:

http://www.who.int/reproductivehealth/publications/fgm/9789241596442/en/index.html
http://www.who.int/reproductivehealth/publications/fgm/fgm-obstetric-study-en.pdf
http://www.who.int/reproductivehealth/publications/fgm/rhr_10_9/en/
5.8.2 Obstetric Fistulae

Obstetric Fistula (OF) is a common, yet often neglected, obstetric complication in countries with a
high prevalence of obstructed labour (and FGM), and contributes to 6% of the maternal morbidity.
Generally accepted estimates suggest that 2-3.5 million women live with obstetric fistula in the
developing world, and between 50,000 and 100,000 new cases develop each year (UNFPA, 2012).
Roughly 2 million women globally live with untreated OF (UNFPA & FIGO, 2002 as cited in WHO,
2006). This RH problem is not often discussed or counselled, yet may cause considerable fear in
women and their SAs, who may not know how to deal with it. The team may consider adding a
session on fistulae if relevant, as it does have specific counselling implications in terms of physical
factors (obstetric care and complications), and emotional or social factors (relationship difficulties,
stigma and low self-esteem).
For more information on obstetric fistulae go to the WHO web site link:
5.8.3 Malaria
Annually, approximately 25 million women in Africa become pregnant and are at risk of developing
Plasmodium falciparum malaria (WHO, 2004). In areas of unstable malaria transmission, these
women have no immunity and pregnancy increases their likelihood of developing severe disease
by two to three times (WHO, 2004). If the country is in an endemic malarial zone, the team could
consider adding a special session to address this priority public health concern as pregnant women
constitute such a high risk group. Collaboration with national malarial experts is advisable. The
signs and symptoms of malaria, and how it impacts on the pregnant woman (febrile illness,
anaemia, cerebral malaria, hypoglycaemia, spontaneous abortion, puerperal sepsis and

haemorrhage), her unborn fetus (stillbirth, prematurity), or her newborn baby (low birth weight,
malaria illness and neonatal death) (WHO, 2004), could be discussed. Prevention strategies
including the need for malaria chemoprophylaxis, and iron supplements, and the protection
provided by impregnated bednets, could be emphasized. Biting patterns of the mosquito could also
be included to help local communities address prevention issues and minimize their exposure at
prime biting times. The fact that malaria is often more dangerous for primigravidae (WHO, 2004;
Macgregor, 1984) could be highlighted. In a population where HIV/AIDS is prevalent, HIV-positive
multigravidae are equally as vulnerable to severe malaria disease as non-HIV-infected
primagravidae (WHO, 2004). Issues around what to do if a pregnant woman develops a fever,
treatment of malaria during pregnancy, and strategies to protect the newborn could also be
included. Images may be added showing pregnant women sleeping under impregnated bednets or
other locally acceptable malaria reduction strategies could be illustrated.
For more information on malaria in pregnancy and a WHO strategic framework for treatment and
control please refer to:
http://www.who.int/malaria/publications/atoz/9789241547925/en/
5.8.4 Adolescents and Women with Special Needs
The MNH Counselling Handbook briefly covers women with disabilities and other populations with
special needs. Each country will have vulnerable groups of women with distinctive needs. Session
2 of the MNH Counselling Handbook deals with the special needs of some groups of pregnant
women. There is an opportunity for the team to develop this section, adding their country’s most
prevalent disabilities and counselling priorities.
Adolescence constitutes a special time in life which can present both prospects and risks for this
susceptible population. The “World Health Report 2005 – Make every mother and child count”
identifies a need to target adolescents to prevent unwanted pregnancies (WHO, 2005)
http://www.who.int/whr/2005/en/.
A subsequent publication The WHO guidelines on preventing early pregnancy and poor
reproductive health outcomes among adolescents in developing countries
(http://whqlibdoc.who.int/publications/2011/9789241502214_eng.pdf?ua=1) includes
recommendations on action and research for increasing the use of skilled antenatal, childbirth and
postnatal care among adolescents. It also includes the recommendations to provide information to
all pregnant adolescents and other stakeholders about the importance of utilizing skilled antenatal
care and skilled childbirth care and to promote birth and emergency planning in antenatal care
strategies for pregnant adolescents (in household, community and health facility settings).
The MNH Counselling Handbook does not address in detail adolescents as a distinct group, as
most of the clinical care is the same, however ensuring access to care for pregnant adolescent
girls and the way information is provided and how they are counselled need special attention. The
approach a health worker or SA adopts to communicate with or counsel a pregnant adolescent girl
will differ from the way he/she counsels an adult woman. It is important to understand the specific
characteristics of adolescents, in order to provide them with age-appropriate, effective and
sensitive care and counselling. Page 26 briefly addresses the counselling needs of pregnant
adolescents.

If the adaptation team wishes to elaborate on this session, there are a number of valuable
resources which may be helpful. WHO/MCA works in the area of sexual and reproductive health as
well as nutrition, development, adolescent-friendly health services, and prevention/care of illness.
Their web site contains a broad-range of studies and resources on adolescents located on:
http://www.who.int/maternal_child_adolescent/topics/adolescence/en/ including the newly released
Health for the world’s adolescents which presents a global overview of adolescents’ health and
health-related behaviours, including the latest data and trends, and discusses the determinants
that influence their health and behaviours. It also features adolescents’ own perspectives on their
health needs - http://www.who.int/maternal_child_adolescent/topics/adolescence/second-
decade/en/
WHO addresses issues related to adolescent HIV/AIDS, specifically why adolescents are affected
by the disease, what can be done, and includes activities and strategies. The documents are
divided into four groups: advocacy papers, technical reports, research and evidence-based studies,
and specific tools and guidelines. One tool the adaptation committee (and policy makers) may find
particularly useful is the counselling guide entitled: “Orientation programme on adolescent health
for health care providers” which aims to strengthen health worker’s understanding of the specific
health care needs of adolescents and help them to learn how to treat this vulnerable group with
more compassion and empathy
(http://www.who.int/child_adolescent_health/documents/9241591269/en/index.html). There are
modules on unsafe abortion, STIs, HIV/AIDS, nutrition and care of the adolescent during
pregnancy and childbirth. There is also a valuable discussion paper on adolescent pregnancy
The WHO publications listed above should provide the adaptation team with extensive guidelines
for the development of adolescent-friendly health care services with a specific focus on maternal
and newborn health. If the adolescent pregnancy rates are very high in your region, the adaptation
team could also consider liaising with youth groups to customize this section.
6. Building Consensus for Adaptation

Once all the adaptations have been made, try to build consensus among the working groups, task
force and other important stakeholders approving the changes before finalizing the document. A
presentation outlining the principal changes could be given to interested parties.
7. Field Testing
Once the entire MNH Handbook has been reviewed, translated, and adapted, field testing should
be conducted. This is an important part of the adaptation process in order to highlight any areas
that have not been properly understood by the SAs, and issues that may not be culturally relevant
to your context. If new sessions have been developed, the field testing provides an opportunity for
the SAs to review this material for the first time, to ensure that they fully understand the new
content. When field testing, it is important to include all cadres of SAs or you may find that much of
the core content is only understood by a small minority of the workforce, and not at health centre
level- depending on the intended users. Remember to choose SAs with a mix of educational levels
and backgrounds and in different health settings (rural, peri-rural and urban) so that you obtain an
accurate picture of how well the newly adapted MNH Counselling Handbook is received and

understood. Different regions or zones in the country may have certain needs, and the design of
the field testing process will need to take this into account.
The field testing should be a participatory consultative process, allowing SAs an opportunity to
comment on different aspects of the MNH Counselling Handbook. A description of the
methodology and a selection of the qualitative tools used in the original field reviews (that can be
amended for use in the field-testing process) is included in Annex 2. For example, a good way to
ensure a session is understood may be to use the observation technique coupled with group
discussions. By observing a group of SAs working through the sessions you will notice any
concepts they find confusing, or areas that are misunderstood. These issues can then be
highlighted in a topic guide, with open-ended questions developed for use during a group
discussion. The information can be compiled, analysed and used to further refine the session.
8. Implementation
Implementation issues will vary by country and will be dependent on the availability of local human,
logistics and financial resources. The following section briefly discusses issues the adaptation team
may like to consider when implementing the MNH Counselling Handbook and scaling it up.
8.1 Production, Distribution and Dissemination

Once the adaptation committee has agreed on the final version of the counselling MNH
Counselling Handbook, it can be produced and distributed to interested organizations.
Harmonization with the different existing programmes is a good way to ensure a better integration
within primary health care settings and structures. Hopefully many of this group will have
participated in the adaptation or field testing process.
A budget and estimation of the time line can be drawn up. Consider human, financial and logistical
resources.
8.2 Introducing the MNH Counselling Handbook

Opportunities for introducing the manual can be discussed by the adaptation committee. One way
to ensure the uptake and sustainability of the MNH Counselling Handbook is to introduce it into
nurses’, midwives' and physicians’ pre-service and in-service training curricula/programmes or
refresher courses. It is a good idea to get different levels of the Ministry of Health (MOH) and donor
commitment to the MNH Counselling Handbook by involving interested parties in key decisions
early on in the adaptation process. It is also important to consider the different levels of health care
in your setting. How the MNH Counselling Handbook is used by SAs in a demanding, large,
comprehensive emergency obstetric care (CEOC) setting may differ from its use in a more remote,
rural, basic emergency obstetric care (BEOC) facility or by a midwife who works in the community.
There are a number of other practical strategies that can be employed when introducing the MNH
Counselling Handbook. If a self-directed learning approach is used, an initial meeting can be held
to present the Handbook to the SAs, where copies can be distributed and sessions assigned for
the SAs to work through. A second meeting can then be scheduled to discuss any problems the
SAs may have encountered while working through it. Field reviews from Sudan and Indonesia
revealed that the majority of SAs would prefer some guidance when first introduced to the MNH
Counselling Handbook. In this case, different sessions could be reviewed by small groups of SAs

and they could then meet up to discuss their progress in a larger group setting, facilitated by a
trained counsellor (or someone familiar with the MNH Counselling Handbook). Each group could
conduct brief presentations highlighting the key issues from each different session/topic to
familiarize all SAs with the content of the MNH Counselling Handbook.
The content of the MNH Counselling Handbook could be used to strengthen other existing
programmes including counselling and MNH programmes, and also to reinforce MNH topics from
the PCPNC.
8.3 Ensuring MNH Counselling Handbook’s Use

There may be a number of barriers to the introduction or sustained use of the MNH Counselling
Handbook. Try to think of all the potential factors in your country that could prevent it from being
used effectively. This issue was addressed in the field reviews. The SAs were asked to identify
motivational factors which would encourage their use of the MNH Counselling Handbook, and also
whether they preferred to use it in groups, with a facilitator or as a self-learning guide. The
response varied by country and by group, but generally the SAs expressed an interest in having a
brief orientation to the MNH Counselling Handbook at its launch, followed by specific facilitated
sessions periodically to ensure they had a comprehensive understanding of the core counselling
concepts and activities.
By brainstorming a list of obstacles, you may be able to come up with a strategy that is more likely
to succeed. Motivational factors for busy SAs who feel they do not have adequate time to use the
MNH Counselling Handbook are important. These factors can be identified by the adaptation
committee and the SAs prior to its introduction. Important motivational factors, including the new
knowledge and skills (both related to counselling practices and new information regarding MNH)
each SA could gain, could be presented at the onset of the training to ensure positive uptake of the
MNH Counselling Handbook. In Sudan, for example, many Sudanese SAs suggested they would
like to receive a counselling certificate, a prize, or new uniforms once they completed the MNH
Counselling Handbook, and this would motivate them to use it consistently with pregnant women,
new mothers, and their families. Indonesian respondents felt the new counselling knowledge would
be an incentive to use the MNH Counselling Handbook, but thought enhanced career prospects, or
some kind of accreditation system would also be a good motivator.
Many countries have Health Education, Information, Education and Communication (IEC) or Health
Promotion departments within their ministries (either in the ministry of health, or the ministry of
information). These departments can play an important role in adapting the MNH Counselling
Handbook, and in devising ways to launch or disseminate its contents. They can also play a role in
developing further support and educational materials for the MNH programmes and for the SA to
use in communication and counselling sessions.
8.4 Training and Supervision

As indicated, the field reviews indicated many SAs would like an initial orientation and brief training
session with facilitators. It may be possible to combine this with an existing meeting of SAs to cut
costs. The training element will largely depend on how and where the MNH Counselling Handbook
is introduced, and whether a self-directed learning, facilitated approach or a combination of the two
is pursued. As discussed in section 8.3, the adaptation committee may decide to introduce the
MNH Counselling Handbook into their SAs’ pre-service training courses, which would provide a

valuable background in counselling and communication concepts early on in the careers of the
SAs, and help to improve the overall quality of care they are able to provide to women and their
newborn.
Supportive supervision was highlighted as crucial by most countries in the field reviews. For SAs
working alone in rural health settings, supervisory visits could clarify any confusing issues and help
motivate them to use the MNH Counselling Handbook.
9. Monitoring and Evaluation

Before introducing the MNH Counselling Handbook, it is recommended that you conduct a baseline
survey, and then after it has been used for a pre-determined length of time (one year, for example),
an evaluation can be conducted to examine whether it has been used consistently by the SAs, and
whether it has improved their counselling and communication skills. The adaptation committee or
sub-groups can consider how they want to evaluate the MNH Counselling Handbook. A baseline
survey of the current knowledge levels and counselling practices of SAs would be a good starting
point, and useful for the purpose of comparison. Table 4 below, provides some suggestions on
evaluation strategies. It is not only important to measure the use of the MNH Counselling
Handbook by the SAs, but also its effectiveness in terms of improving the SAs’ counselling skills
and practices, women's use of services, and women’s and community’s knowledge of some of the
key information, as well as their overall satisfaction with the care they receive. Feedback can be
used to make further adaptations to the MNH Counselling Handbook, or to the implementation
strategies as required. If any problems are revealed, the adaptation committee may want to
consider making further changes before re-distribution of the MNH Counselling Handbook.

Table 4 Evaluating the MNH Counselling Handbook
Use Effectiveness
Observe SAs in health facilities using a Measure satisfaction levels of women post counselling session
structured checklist to see whether they are through exit interviews (pre and post Handbook introduction).
using principles of counselling and referring to • Were they able to ask questions?
Handbook. • Were they part of the conversation?
• Did they make their own decisions/ plans?
• Could they follow-through on these decisions/plans?
• Were there any improvements noted after the introduction
of the Handbook?
Conduct exit interviews with women post Hold discussions with SAs to explore their perceptions of whether
ANC, after birth or postpartum visits to their counselling skills have improved. Hold discussions with women
determine whether there was two-way or one- and families to explore their perceptions of whether the SAs’
way communication. counselling skills have improved.
Hold discussions with SAs to explore Conduct a test prior to introducing the Handbook and after training or
Handbook’s uptake and any barriers to observe SAs using a structured checklist- containing key counselling
uptake. skills- to measure any changes in skill levels.
Are Birth and Emergency preparedness cards now used? I.e. If you
have a baseline of use, then you can determine whether there has
been an increase in use.
• Is there an increase in knowledge in the population
regarding danger signs?
• Is there an increase in the number of community transport
plans?
• Is there an increase in births assisted by a SA?
• Has there been a decrease in the length of time it takes a
woman in labour to reach hospital?
There are many questions that can be added to other studies to
determine whether knowledge or certain behaviours have changed.

10. Adaptation Bibliography
This adaptation guide was based on the following sources:
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World Health Organization. Counselling for maternal and newborn health care: A handbook for
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Annex 1
MNH Counselling Handbook References by subject

Abortion
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family planning perspectives (2003). 126-129.
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technical and policy guidance for health systems. Second edition. World Health Organization,
Geneva, 2012
World Health Organization. Clinical practice handbook for safe abortion. World Health
Organization, Geneva, 2014
Adherence
Vermeire, Etienne, et al. Patient adherence to treatment: three decades of research: A

comprehensive review. Journal of clinical pharmacy and therapeutics 26.5 (2001): 331-342.
World Health Organization. Adherence to long-term therapies. Evidence for Action. World Health
Adolescents
Brown A D, Jejeebhoy SJ, Shah I, Yount KM. Sexual relations among young people in developing
countries: evidence from WHO case studies. Dept of Reproductive Health and Research. World
Health Organization, Geneva, 2001
World Health Organization, Adolescent Health Programme. Counselling skills training in adolescent
sexuality and reproductive health: a facilitator’s guide. World Health Organization, Geneva, 1993.
World Health Organization. Adolescent job aid: A handy desk reference tool for primary level health
workers. World Health Organization, Geneva, 2010
World Health Organization. Preventing early pregnancy and poor reproductive outcomes among
adolescents in developing countries. World Health Organization, Geneva, 2011
World Health Organization. Making health services adolescent friendly: developing national quality
standards for adolescent friendly health services. World Health Organization, Geneva, 2012
Client-Provider Interaction
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Heinemann. 1996.
Murphy, E. M. Best practices in client-provider interactions in reproductive health services: a review

of the literature. MAQ Initiative. 2001.

Ringheim, Karin. When the client is male: client-provider interaction from a gender perspective.
International Family Planning Perspectives (2002): 170-175.
Rollnick S, Miller WR. What is Motivational Interviewing? Behavioural and Cognitive

Psychotherapy, 23: 325-334. 1995.
Kim, Y. M., Lettenmaier, C., Odallo, D., Thuo, M., & Khasiani, S. Haki Yako: a client provider
information education and communication project in Kenya. Johns Hopkins School of Public
Health. 1996
Community as partners
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Lippincott Williams & Wilkins. 2010.
Kureshy, N. MotherCare’s Community Assessments: Understanding family and community

behaviours and practices. MotherCare Matters 8.3-4 (2000).
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and newborn health. World Health Organization, Geneva, 2010
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participatory learning and action cycles with women’s groups for maternal and newborn health.
World Health Organization, Geneva, 2014
Couple Counselling
Becker S. Couples and reproductive health: A review of couple studies. Family Planning 27 (6):
291-306. 1996
DeRose, Laurie F., et al. Does discussion of family planning improve knowledge of partner's
attitude toward contraceptives? International Family Planning Perspectives (2004): 87-93.
Mishra, A., Das, A., Ottolenghi, E., Huntington, D., Adamchak, S., Khan, M. E., & Homan, F.
Involving men in maternity care in India. Frontiers in Reproductive Health, Population Council.
2004.
Counselling Tools and Aids

Bosompra, K. Dissemination of health information among rural dwellers in Africa: a Ghanaian
experience. Social Science and Medicine 29(9):1133-1140, 1989.
Centre for health and population research. Picture cards explain pregnancy complications. Safe
Motherhood Newsletter (23):3, 1997.
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in family planning service delivery in Tunisia. Studies in Family Planning, 1987, Vol.18, No.4,
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Goodwell, V. Posters as a health education medium in a rural setting [letter]. National Medical
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274, 1990.
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entertainment-education radio soap opera on family planning behavior in Tanzania. Studies in
Family Planning. 30(3):193-211, 1999.
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Decision-making and client involvement

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patients’ power messages. Patient Education and Counselling 47: 101-113. 2002.
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counselling – A way to empowerment? Health Education Journal 62 (4): 326-340. 2003.
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Planning: The Davao Project. Studies in family planning, 32(4), 302-314. 2001.
Family Planning Counselling
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tool for family planning clients and providers. World Health Organization, Geneva, 2005
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planning for community health workers and their clients. World Health Organization, Geneva, 2012

HIV/ AIDS
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and care. Five case studies related to prevention of mother-to-child transmission of HIV,
tuberculosis, young people, and reaching general population groups. UNAIDS. 2002
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Cochrane Library 4, 2004.
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infected women: guidelines on HIV-related care, treatment and support for HIV-infected women
and their children in resource-limited settings. World Health Organization, Geneva, 2004.
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generic training package. World Health Organization, Geneva, 2004.
World Health Organization. Adolescent HIV testing, counselling and care. World Health
World Health Organization. Caring for newborns and children in the community, adaptation for high
HIV or TB settings. World Health Organization, Geneva, 2014
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Geneva, 2010
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people living with HIV. World Health Organization, Geneva, 2009
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the health sector: progress report 2010. World Health Organization, Geneva, 2010.
Infant Feeding Practices

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Review of Current Scientific Knowledge. World Health Organization, Geneva, 1998.
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World Health Organization; UNICEF. Complementary feeding counselling: A training course.
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medical students and allied health professionals. World Health Organization, Geneva, 2009
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Sexual Health
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health programmes: A framework for action. World Health Organization, Geneva, 2010
Transportation and Waiting Homes

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Naker D, Michau L. Rethinking domestic violence: A training process for community activists.
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regard to sexual violence in conflict-affected settings. World Health Organization, Geneva, 2012
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women. World Health Organization, Geneva, 2013
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HIV epidemic. World Health Organization, Geneva, 2013

Annex 2
Summary of Methodology for Field Reviews5 &

Tools
5For full copies of the field reviews in the Philippines, Sudan, Indonesia and the Global Summary Report, please write to A.
Portela of WHO/MCA at portelaa@who.int. See Section 2.2 of a description of reviews done in each setting.

1.0 Objectives of the Field Reviews
The main objectives of the field reviews in Indonesia and Sudan were:
1. To determine the comprehensibility, usability and acceptability of the Handbook by the
Indonesian and Sudanese SAs
2. To identify amendments needed in the Handbook to maximize its function for improved
counselling and communication skills by the SAs
3. To explore country processes for future use of the Handbook including introduction,
adaptation, and training of SAs to achieve competency in counselling and communicating
issues.
2.0 Summary of Methods

The methodology and research tools employed were identical in each country. Six methods were
combined to ensure a degree of validity to the findings. An additional Focus Group was required in
Sudan as the selection criteria of the respondents initially excluded a large proportion of the least
qualified (but most prevalent) rural SAs who were deemed the most likely target group to use and
benefit from the Handbook.
1. Summary of data synthesized from 30 comment sheets (15 per country) filled out prior to
the consultant’s arrival
2. Four Key Informant Interviews:
a. Indonesia: Dr. Laura Guarenti (WHO MCH Medical Officer), and Ms. Anne Hyre
(Senior Midwifery Advisor, MNH, responsible for maternal health communication
manual)
b. Sudan: Dr. Firdous (Head of Reproductive Health Unit in the MOH), and Dr. Ragia
and Dr. Hassan (Senior UNFPA Managers).
3. Ten In-Depth Interviews (five per country) with SAs
4. Three Group Discussions: One in Indonesia and two in Sudan to compensate for the initial
sampling limitations
5. Two Observation techniques (one per country) involving a total of eight respondents
6. Two final consensus-building summary Workshops (one per country) with all 30
respondents
3.0 Process
Detailed comment sheets were handed out to all 30 SAs two weeks before the start of the
consultancy. These were completed in English by the Sudanese respondents, and translated into
Bahasa for the Indonesian respondents. The comment sheets were then gathered at the start of
the consultancy, analysed and recorded. Problem areas, interesting comments or sections that
were misunderstood were reviewed with the SAs prior to the Workshop.
Key Informant Interviews were held with stakeholders possessing pertinent knowledge related to
counselling skills and existing national counselling and/or communication resources or training
programmes for SAs. These were conducted in English using an amended version of the Interview
topic guides and lasted one to two hours each.
In-Depth Interviews were conducted using translated topic guides for the Indonesian SAs and
English guides for the Sudanese SAs.

The comment sheets for each SA were reviewed at this time and any clarifications were made.
These interviews lasted two hours each and the transcriptions attempted to use verbatim
quotations. The Country Link in Indonesia conducted these interviews along with the WHO Link
person who then translated each Interview for the consultant.
The three Group Discussions were conducted using topic guides with homogenous groups of SAs
and provoked lively debate. These lasted between one and a half to two hours each. These were
transcribed immediately and the data analysed each evening. One Group Discussion per country
was conducted in English but the supplemental group added in Sudan with six lower level Village
Midwives was conducted in Arabic using an abbreviated version of the topic guide. This group, due
to the time constraint and lack of initial inclusion in the study, had reviewed only one session (8- on
danger signs, which was translated into Arabic by the Country Link Person at the start of the
consultancy).
Four respondents per country were also observed working through one session of the Handbook
they had not previously reviewed. In Indonesia they reviewed Session 8 (Danger Signs) and in
Sudan they reviewed Session 10 (Support during Labour). These sessions were observed by
three members of the review team in each country who took notes during the process then held a
discussion at the end of each Observation. It took each group about one hour to work through their
designated session.
The final method employed in this review culminated in a consensus building summary Workshop
with all 15 respondents per country. Data from the five above methods was analysed carefully and
themes were presented to the Workshop sub-groups for them to reach an agreement on issues
related to the Handbook (including use, language, content, length etc.). The Workshop took six
hours in Indonesia and five hours in Sudan. Respondents had been given exercises to complete in
their groups several days before the Workshop (titles, images, problem areas) to facilitate the
process on the day of the Workshop and ensure more critical input.
4.0 Tools used in Field Reviews

The following tools were used with groups of SAs in Sudan and Indonesia (and were amended
from the feedback following field reviews in Malawi and the Philippines).
4.1 Observation Tool

Observation of a group of SAs working through one Handbook session
Welcome the group and start with a presentation of yourselves (the observers), the participants,
and an explanation of the review process as part of the process of the adaptation of the handbook,
present the next steps for the development, and then present the objectives of this observation
session.

Use the following headings to guide comments on your observations:
1. Timing of Session
• Start time:
• Finish time:
• Time session took to complete:
• Estimated time taken on each activity (specify for each):
2. Background information about the skilled attendants:

• Age:
• Sex:
• Qualifications:
• Average number of monthly deliveries:
• Setting of health centre- Rural or Urban:
• Length of time working as a skilled attendant:
• Length of time at this health facility/current position:
• Previous training on counselling and communication skills:
3. Comprehension
• Understanding of content
• Understanding of instructions for activities
• Difficulties encountered and how /(if) resolved:
4. Process
• How was the session approached – individually or as a group?
• Was a facilitator or chair elected?
• Did they read through whole session before going back activities or did they work through
section by section?
• Please describe any areas of consensus and disagreement and the process used to
resolve.
• Observers’ opinion of comfort with self-learning approach vs. a facilitator?
5. Activities
• Were the activities completed?
• Problems with activities (what and why)
• Observers’ opinion – How well does the commentary ("Our view", at the end of each
activity) match with how the activity was carried out by the group? Does the commentary
reinforce what they did?
6. Learning and Self-reflection

• Did the group members share ideas or previous experiences? Examples:
• Did the group members refer information in the handbook back to their own practice?
Examples

7. Closure
• Ask participants their opinion about the session
• Were the objectives of the session met? Why or why not?
• What do they think about the self- learning approach?
• Did they find the activities useful?
• Do they have any suggestions to improve the session?
THANK THE PARTICIPANTS FOR THEIR COOPERATION

4.2 Topic Guide for the In-depth Interviews
Welcome the participant, introduce yourself and explain the objectives of the review process for the
adaptation of the Handbook, and the main objectives of the in-depth interview. Assure him/her that
his/her feedback and time is greatly appreciated. We encourage him/her to be as honest as
possible as this information will be of great use to us.
1. Timing of Interview
• Start time:
• Finish time:
2. Background information about the skilled attendant:

• Age:
• Sex:
• Qualifications:
• Setting of health centre- Rural or Urban:
3. Ask the SA to review in-depth one session (or the newly written session) before the interview.
She/he can write comments and observations for you to go through together in a discussion
format.
• Review with the SA the session with his/her comments and observations, trying to get a
feel for the extent of the comments, i.e. are they isolated, is it something that repeats
through the various sessions.
• Ask questions as you go through the pages, such as her/his view about the commentary in
relation to the activity in this session, any words which you think he/she may not be
familiar, etc.
• Review the images of this selected session.
• Ask the SA whether he/she thinks the session’s aims and objectives were met.
4. General impression of the handbook
Go through each of the bullets below and rank them according to the scale provided. Ask
him/her to provide an explanation of each response.
• Usefulness of handbook Very useful Useful Not useful
Too short Fine Too long
• Length of handbook

Too Easy Fine Too Difficult
• Language
Very Clear Clear Confusing
• Presentation/Format/layout
Excellent Fine Bad
• Images
5. Counselling for Decision-Making

• Could you explain in your own words what this means?
• What is the difference between Counselling for Decision-Making and Providing
Information?
• How could your interactions with women contribute to their empowerment?
• Does the book help you to develop the skills to do this? If so, why? If not, what should we
change?
• After having gone through the handbook, what do you think you will do differently in your
work with women, their partners and their families?
6. Knowledge and Skills

• Was the information contained in handbook new to you? Please specify.
• Which of these skills did you already have before using the handbook?
o questioning skills
o communication skills
o listening skills
o others (explain)
• Do you feel you developed new skills in any of these areas after using the handbook? (Do
not repeat if mentioned above.)
o questioning skills,
o communication skills
o listening skills
o others (explain)
• Any skills, information or content missing in the handbook which should be added?
• Any skills, information or content in the handbook which should be removed? Why?
7. Use of Handbook
• In general, did you find the handbook useful? Why?

• What is the likelihood of the other SAs completing activities when not part of a formal
review process – i.e., in a normal work day?
• What would encourage or motivate other SAs to work through the handbook?
• Anything else you wish to add?
THANK THE SKILLED ATTENDANT FOR HIS/HER COOPERATION

4.3 Topic Guide for Group Discussion
The group discussion begins the process of consensus building. The group discussion will revisit
many of the areas already examined through the interviews, observations but the discussion
should highlight areas of conflict and consensus to take forward to the adaptation taskforce for
consideration.
Introduction
Welcome the group. Start with a presentation of the facilitator and observer, the participants, an
explanation of the review process as part of the process of the adaptation of the handbook, present
the next steps for the development, and then present the objectives of this group discussion.
Encourage their participation and ask them to be as open as possible as their suggestions will be
very useful to us in adapting the handbook to suit the local country context.
NOTE: As the facilitator you should try to reach some consensus on the points rather than just
individual responses. Also remember, you are not conducting an interview but are trying to
facilitate an active discussion among the participants.
1. Background information about the skilled attendants:

• Age:
• Sex:
• Qualifications:
• Setting of health centre-Rural or Urban:
2. Knowledge and Skills of SAs in Counselling and communication

• Describe the SAs in your district (i.e., doctors, midwives, and nurses).
• What kind of training do they receive in counselling and/or in communication?
• In your opinion, is this an important area of the work of a SA?
• What is your opinion about the skills of SAs in their district in this area?
• What are some common weaknesses of SAs in counselling and communication?
3. General impression of the handbook

• What is your general opinion of the handbook?
• What did you like most about the handbook? (As a group, come up with three points)
• What did you like least about the handbook? (As a group, come up with three points)
4. Self-Directed Learning Approach

• What is your opinion about the self-directed learning approach used in the handbook?
• How comfortable were you with a self-directed learning approach?
• Is this a useful way for other SAs in your district to learn these skills?

• Do you think SAs in your district would prefer a more formal training session?
5. Use of the Handbook

• For those who know the PCPNC, is this handbook useful as companion guide? Why?
• Is the content applicable to everyday work/practice? Why?
• What is the likelihood of the other SAs completing activities when not part of a review– i.e.,
in everyday practice?
• What would encourage or motivate other SAs to work through the handbook?
6. Language
• Any terms in particular which you did not understand?
• Any terms in particular that you think other SAs will not understand?
Closing
THANK THE PARTICIPANTS FOR THEIR COOPERATION

Annex 3
Summary of Recommendations from Field Reviews

Recommendations from the Field Review in Khartoum, Sudan
• Translate the Handbook into Simple Arabic. Field-test the translation and conduct a back-
translation into English for quality assurance purposes
• Conduct a small Pilot study with rural Village Midwives to ensure concepts are well understood
• Consider adapting the Handbook into radio cassettes for the illiterate rural midwives
• Add a section on Female Genital Mutilation as FGM is prevalent in 90% of women in Sudan (CBS
2001), and all respondents unanimously agreed on the importance of adding information devoted
to this harmful practice which requires special technical and counselling expertise. One discussion
in the workshop considered whether FGM sections could simply be added into each existing
session. However, only two respondents (out of 15) were in favour of this. There is an Information,
Education, and Communication (IEC) FGM Working group in Sudan and two local FGM guidelines6
that could be important sources of information if a new session is endorsed by the taskforce.
• Consider the possibility of … a Sudanese FGM group using existing guidelines with below
suggestions from one SA taken from an in-depth interview in an urban setting in Sudan:
“As the topic is new to me I really don’t know but I do think an entire session on Female
Genital Mutilation is critical. It is a very big problem in our country and holds with it many
difficulties in reproductive health such as first intercourse, and labour-even just physical
examinations and catheterisations. Although men are slowly changing their ideas about it, the
grandmothers still insist on this. We need to include a definition, the types of FGM, and mainly
about the disadvantages (infection, bleeding, and disease transmission). The handbook
should discuss the problems with counselling and examining these circumcised women. It can
also refer to the guidelines developed.”
• Ensure more detailed explanations of key concepts of gender and empowerment
• Amend the images to effectively reflect the Sudanese cultural context
• Ensure less selection bias with the intended users for the next stage of the review
• Introduce the ECPG manual into Sudan or, if this is not a feasible option, consider adding more
technical information to this Counselling Handbook
6
Two Sudanese Guidelines available on FGM are: “FGM in the Sudan: A Community-Based Study” by the Sudan Fertility
Care Association (UNFPA & FPIA), March 2001; and “Strategy and Action Plan: To Abolish FGM in Sudan” MOH, November
2002.

Recommendations from the Field Review in Serang District, Banten Province, Indonesia
• Re-translate the Handbook into simpler Bahasa Indonesian. Field-test the translation and conduct
a back-translation into English for quality assurance purposes. Ensure the translation of the more
complex terms outlined above is re-translated and extensively field tested to ensure better
understanding.
• Simplify the compound sentences
• Clarify concepts of “gender” and “empowerment” and include more detailed explanations and
practical examples
• Amend the images to effectively reflect the Indonesian cultural context
• Consider the use of certain sessions (AIDS and Bereavement) to add into existing manuals if the
MOH does not yet want to invest in another communications manual.
• Consider a comparison study of all available/existing communications manuals with the Handbook
to test effectiveness and use among SAs in Indonesia.
Recommendations from Field Review : Manila, The Philippines
All the participants recommended the adoption the Handbook if their programme was interested in
improving the skills of SAs in counselling and communication.
In order to ensure that the Handbook is more applicable and responsive to local needs and context, they
suggested the following (besides all changes suggested in the previous discussions):
• Provide an orientation to the health workers before they start using the Handbook
• Organize prerequisite training e.g. BF, FP, PCPNC
• Define target groups
• Add counselling for specific target groups and special needs for instance teenage pregnancy,
adolescents
• Adjust the Handbook to ‘Sentrong Sigla’ quality standards (standards adopted by Metro
Manila Health Department)
• PCPNC is endorsed by the country
• Introduce the counselling Handbook and provide an orientation on its use during the PCPNC
training
The participants thought that the Handbook contributes to improving maternal and newborn health because
of the following:
• Clients are empowered

• The emphasis is put upon the importance of working with support group especially in
preparing birth plans
• Handbook serves as a guide in providing quality health services
• It helps women and families to gain additional knowledge and to be more ‘compliant’.
In conclusion, in addition to the recommendations from the Philippines team, the following suggestions are
put forth for consideration:
• Reinforce the skills development part of the Handbook by strengthening the activities so that they
lead in a practical way to developing the skills for counselling. For instance, some activities could

be designed as group exercises among the SAs where they could support each other in developing
these skills through observation and feedback, role-play.
• The key concepts of the Handbook need to be defined and reinforced throughout the Handbook.
Additional exercises may need to be designed to help the SAs to understand and internalise some
of the concepts presented at the beginning of the Handbook. This would avoid misinterpretations
and allow self-reflection on a sound basis.
When introducing the Handbook, programmes have to plan a strategy where the SAs have the opportunity
to spend time working through the Handbook. This may entail a briefing by the supervisors, a different
organization of duties and possibly arranging group sessions and exercises.

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A handbook for building skills

Counselling for Maternal

ACKNOWLEDGEMENTS ................................................................................................................................ III

WHO Adaptation Guide for MNH Counselling Handbook i

BOX 1 MNH COUNSELLING HANDBOOK'S OBJECTIVES ................................................................................................................ 1

FIGURE 1 SCHEMATIC OVERVIEW OF THE COUNSELLING PROCESS.............................................................................................. 4

WHO Adaptation Guide for MNH Counselling Handbook ii

WHO Adaptation Guide for MNH Counselling Handbook iii

AIDS Acquired immunodeficiency syndrome

ANC Antenatal care

ARV Antiretroviral drug

BEOC Basic emergency obstetric care

CEOC Comprehensive emergency obstetric care

FGM Female genital mutilation

HIV Human immunodeficiency virus

IEC Information, education and communication department

IUD Intrauterine Device

LAM Lactational Amenorrhoea Method

MCA Maternal, Newborn, Child and Adolescent Health

MCH Maternal and child health

MNH Maternal and Newborn Health

PLPWA People Living Positively with AIDS

PMTCT Prevention of mother-to-child transmission

SAs Skilled Attendants

STIs Sexually transmitted infection

TBAs Traditional Birth Attendants

WHO World Health Organization

WHO Adaptation Guide for MNH Counselling Handbook iv

WHO Adaptation Guide for MNH Counselling Handbook 1

2. About the MNH Counselling Handbook

WHO Adaptation Guide for MNH Counselling Handbook 2

Box 2: MNH Counselling Handbook's Topics

Box 2 MNH Counselling Handbook’s Topics

WHO Adaptation Guide for MNH Counselling Handbook 3

2.4 Key Principles

o the woman making health decisions in partnership with the SA

WHO Adaptation Guide for MNH Counselling Handbook 4

If a different definition of SA is used by certain countries, or the MNH Counselling Handbook is to

3.1 Assessing the Need to Adapt

3 The MNH Counselling Handbook may be used in pre-service or in-service training.

WHO Adaptation Guide for MNH Counselling Handbook 5

Department of Maternal, Newborn, Child and Adolescent Health (MCA)

Tel.: +41 22 791 3281

3.2 Process of Adaptation

Figure 2. Flow Diagram: Suggested Adaptation Process

Appoint Adaptation Committee

Develop Terms of Reference

Is it aligned with National Policies?

WHO Adaptation Guide for MNH Counselling Handbook 6

3.2.2 Develop the Terms of Reference

3.2.3 Review the MNH Counselling Handbook4

WHO Adaptation Guide for MNH Counselling Handbook 7

WHO Adaptation Guide for MNH Counselling Handbook 8

Box 3 Translation Tips

• It is important to keep the essence /integrity of the MNH Counselling Handbook.

5.1 Links with PCPNC

WHO Adaptation Guide for MNH Counselling Handbook 9

Content MNH PCPNC Adaptation

WHO Adaptation Guide for MNH Counselling Handbook 10

Clean home delivery M8-M9