A BOOK FOR MIDWIVES

A Book  for  Midwives

Care  for  pregnancy,  birth,
and  women's  health

Susan  Klein,  Suellen  Miller,
and  Fiona  Thomson

Hesperian

Berkeley,  California,  USA

The  Hesperian  Foundation  and  the  contributors  to  A Book  for  Midwives  do  not  assume
liability  for  the  use  of  information  contained  in  this  book.

All  health  workers  have  a responsibility  to  be  honest  with  themselves  and  the  people  they
care  for  about  the  limits  of  their  skills.  This  means:  only  perform  the  procedures  you  are
trained  to.  Find  help  from  other,  more  experienced  health  workers  when  a woman  needs  a
kind  of  care  that  you  are  not  experienced  with.  Seek  the  advice  of  local  health  workers  and
medical  authorities  about  the  safest  ways  to  practice  in  your  area.  This  manual  can  help
you  learn  new  skills,  but  no  book  can  take  the  place  of  hands-on  training  with  a skilled  and
experienced  teacher.  Keep  watching,  reading,  listening,  and  learning  more  whenever  you
have  the  chance.

Copyright  © 2004,  2009,  201 0 by  the  Hesperian  Foundation.  All  rights  reserved.

First  edition:  December  2004,  2nd  printing  2009,  update  201 0

Printed  in  USA

ISBN:  978-0-942364-23-1

Library  of  Congress  Cataloging-in-Publication  Data

The  Library  of  Congress  has  already  cataloged  the  1 0-digit  ISBN  as  follows:

Klein,  Susan,  b.  1 948.

A book  for  midwives  : care  for  pregnancy,  birth,  and  women's  health  / by  Susan  Klein,
Suellen  Miller,  and  Fiona  Thomson.-- 1 st  ed.
p. ; cm.

Includes  index.

ISBN  0-942364-23-6  (pbk.)

1 . Midwifery.  2.  Midwives.  3.  Pregnancy.  4.  Childbirth.  5.  Women-Health  and  hygiene.
I.  Miller,  Suellen,  1 947-  II.  Thomson,  Fiona,  1 974-  III.  Hesperian  Foundation.  IV. Title.
[DNLM:  1 . Midwifery.  WQ  1 65  K635b  2004]

RG960.K56  2004
618.2— dc22

2004060651

The  Hesperian  Foundation  encourages  others  to  copy,  reproduce,  or  adapt  to  meet  local
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Berkeley,  California  94704,  USA
www.hesperian.org

nesperian

This  book  con  be  improved  with  your  help.  We
want  to  hear  about  your  experiences,  traditions
and  practices.  If  you  have  any  suggestions  for
improving  this  book , or  making  it  better  meet
the  needs  of  your  community,  please  write  to  us.
Your  comments  will  help  make  future  editions
more  useful.  Thank  you  for  your  help.

Credits

Project  coordination:  Fiona  Thomson

Design  and  production:  Sarah  Wallis

Cover  design:  Sarah  Wallis

Additional  writing  and  editing:

Darlena  David,  Todd  Jailer,

Jane  Maxwell,  Susan  McCallister,

Sarah  Shannon,  Kathleen  Vickery,

Sarah  Wallis

Art  coordination:  Fiona  Thomson
and  Sarah  Wallis

Additional  production:  Lora  Santiago

Artists:  Namrata  Bali,  Jennifer  Barrios,

Sara  Boore,  Heidi  Broner,

May  Florence  Cadiente,  Barbara  Carter,
Gil  Corral,  Elizabeth  Cox,

Regina  Faul-Doyle,  Christine  Eber,

Inaki  Fernandez  de  Retana,

Sandy  Frank,  Deborah  Green,

Susie  Gunn,  Jesse  Hamm,  Haris  Ichwan,
Anna  Kallis,  Delphine  Kenze,

Susan  Klein,  Joyce  Knezevich,  Gina  Lee,
June  Mehra,  Naoko  Miyamoto,

Jeanne  Muller,  Mabel  Negrete,

Gabriela  Nunez,  Kate  Peatman,

Sara  Reilly-Baldeschwieler,

Diana  Reiss-Koncar,  Petra  Rohr-
Rouendaal,  Leilani  Roosman,

Lucy  Sargeant,  Mona  Sfeir,

Akiko  Aoyagi  Shurtleff,  Chengyu  Song,
Fiona  Thomson,  Dovile  Tomkute-
Veleckiene,  Sarah  Wallis,  Lihua  Wang,
David  Werner,  Christine  Wong,

Allan  Woong,  Mary  Ann  Zapalac

Field-testing  and  networking:  Starr  Amrit
Copy  editing:  Rachel  Markowitz
Indexing:  Ty  Koontz
Proofreading:  Sunah  Cherwin

Medical  review:  Ellen  Israel,  Lisa  Keller,
Melissa  Smith,  Judith  Standley

Editorial  and  production  management:

Susan  McCallister

Cover  photographs:

1

2

1 . India  by  Starr  Amrit

2.  Nepal  by  Curt  Carnemark/World  Bank

3.  Mexico  by  Rick  Maiman/David  and
Lucile  Packard  Foundation,  courtesy  of
Photoshare

4.  Democratic  Republic  of  Congo  by
Gilberte  Vansintejan

5.  Tunisia  by  Curt  Carnemark/World  Bank

6.  Burma  (Myanmar)  by  Peter  Williams/WCC

Back  cover:  Mexico  by  Rick  Maiman/

David  and  Lucile  Packard  Foundation,
courtesy  of  Photoshare

The  first  edition  of  this  book  was  imagined,  written,  and  illustrated  by  Susan  Klein.
Sadly,  she  died  before  it  was  published.  This  new  revision  is  still  carried  largely  by  her
writing,  her  drawings,  and  we  hope,  her  vision  — that  A Book  For  Midwives  would  be  a
tool  enabling  all  those  who  attend  women  in  childbirth,  regardless  of  their
educational  background,  to  exercise  independent  judgment  and  to  make  the  best
possible  decisions  at  each  birth.

Credits  for  the  2009  edition  and  201 0 update:  This  updated,  corrected  printing  relies
heavily  on  the  generously  offered,  wise  counsel  of  midwives  Ellen  Israel,  Ellen  Lapowsky,
Suellen  Miller,  Judith  Standley,  and  Sarah  Wallis;  and  Drs.  Reuben  Granich,  Lisa  Keller,
Scott  Oesterling,  Linda  Spangler,  Amy  Stenson,  and  Lorna  Thornton.  Todd  Jailer
coordinated  the  reprint  with  editorial  and  design  assistance  from  Shu  Ping  Guan,  Jane
Maxwell,  Susan  McCallister,  Kathleen  Tandy,  Dorothy  Tegeler  and  Fiona  Thomson.

www. nespcnaii.org

Thanks

Only  with  the  collaboration  of  hundreds  of  advisors,  reviewers,  writers,  artists,  and  others
was  it  possible  to  create  this  book.

Every  staff  member,  intern,  and  volunteer  here  at  the  Hesperian  Foundation  helped  bring
this  book  into  the  world,  including  those  who  raise  funds,  manage  finances,  publicize  our
books,  and  pack  and  ship  them  around  the  world.  Outside  our  office,  dozens  of  reviewers
helped  decide  what  this  book  should  cover  and  how  to  do  it.  Groups  of  midwives  and
midwifery  students  in  1 0 countries  critiqued  early  versions  to  make  it  as  useful,  appropriate,
and  accurate  as  possible.  Midwives,  doctors,  and  other  health  workers,  trainers,  and
specialists  volunteered  their  time  to  ensure  the  accuracy  and  clarity  of  the  material  here.

Along  with  our  tireless  medical  editors,  we  called  on  a few  reviewers  over  and  over
again,  and  they  deserve  special  mention  here.  Thank  you  Deborah  Billings,  Lisa  de  Avila,

Ruth  Kennedy,  and  Karen  Strange.

The  following  organizations  contributed  time,  resources,  and  critical  thinking:  Averting
Maternal  Death  and  Disability  (AMDD)  in  the  US;  ASECSA  in  Guatemala; The  Bangladesh
Women's  Health  Coalition;  The  Berkeley  Midwives  Study  Group  in  the  US;  El  Centro  Para  los
Adolescente  de  San  Miguel  de  Allende  (CASA)  in  Mexico;  Centre  For  Rural  Studies  and
Development  in  India;  El  Centro  de  Atencion  Integral  de  la  Pareja  in  Mexico;  The  International
Confederation  of  Midwives;  The  Integrated  Midwives  Association  of  the  Philippines;
Inuulitsivak  Maternity  Center  in  Canada;  Ipas  in  the  US,  Ghana,  and  Kenya;  Ixmucane  and
Midwives  for  Midwives  in  Guatamala;  Jamkhed  Comprehensive  Rural  Health  Program  in  India;
Kampot  Hospital  Maternity  Center  in  Cambodia;  the  Maryknoll  Sisters  and  the  VEMA  training
center  of  Tanzania;  Pathfinder  in  Peru;  and  the  Reproductive  Health  Research  Unit  at  the
University  of  the  Witwatersrand,  Chris  Hani  Baragwanath  Hospital  in  South  Africa.

Thanks  to  the  following  publishers  who  gave  us  permission  to  use  drawings:  Family  Care
International,  from  Healthy  Women,  Healthy  Mothers;  Freedom  From  Hunger;  and  Pesticide
Action  Network  Asia  and  the  Pacific,  from  Breaking  the  Silence!  Plantations  and  Pesticides.

Our  deep  gratitude  goes  to  everyone  who  gave  their  time,  thoughts,  and  knowledge
so  generously,  both  to  the  original  edition  of  A Book  for  Midwives  and  to  this  revision.

Your  commitment  to  health  for  all  is  what  brought  this  book  into  the  world.  Thank  you:

Hilary  Abell
Dee  I Afroze
Arthur  Ammann
Jana  Anderson
Susan  Anderson
Shoba  Arole
Leonor  Bahena  Erazo
Alison  Bastien
Naomi  Baumslag
Denise  Bergez
Erik  Bergstrom
Alan  Berkman
Ginger  Bhakti
Deborah  Bickel

Judith  Bishop
Lisa  Bohmer
Bill  Bower
Jenny  Bowers
Kate  Bowland
Isabel  Brabant

Barbara  Briggs-
Letson

Sandy  Buffington
Colin  Bullough

Raquel  Burgos
Medina

August  Burns
Pauline  Butcher
Sarah  Buttrey

Ana  Maria  Camarillo
Kristen  Cashmore

Teresa  Cerezo
Gonzalez

Rebecca  Chalker
Barbara  Clifford
Davida  Coady
Rani  Coelho
Timothy  Coen
Jeff  Conant
Peggy  Cook
Maureen  Corbett

Antonia  Cordova
Morales

Maricruz  Coronado

Jennie  Corr
Kyle  Craven
Jane  Crawley
Alice  de  la  Gente

Maria  de  la  Paz
Puebla  Alvear

Barbara  de  Souza
David  de  Leeuw
Kim  Dickson-Tetteh
Milka  Dinev
France  Donnay
Peg  Donovan

Carol  Downer-
Chatham

Jane  Drake

A Book  for  Midwives  (201  0)

www. nesperian.org

J.T.  Dunn
Edith  Eddy

Sylvia  Estrada-
Claudio

Aryn  Faur
Susan  Fawcus
Juliet  Fleischl
Nina  Frankel
Carmen  Frazier
Frances  Ganges
Tracy  Gary

Marlene  Gerber-
Fried

Julie  Gerk
Zafarullah  Gill
Ruth  Goehle
Fisa  Gonzalves
Nadine  Goodman
Suzan  Goodman
Kristen  Graser
James  Green
Sadja  Greenwood
Cindy  Haag
Barb  Hammes
Marcia  Hansen
Roxanne  Henderson
Griselda  Hernandez
Kathy  Herschderfer

Sarah  Jane
Holcombe

Diana  Hoover
Nap  Hosang
Jennifer  Houston
Mary  Clare  Hubert
Kathleen  Huggins

Pamela  Hunt
Robert  Hurst
Peter  Ivey
Nuriya  Janss
Christine  Johnson
Mary  Johnson
Ralph  Johnson
John  Kadyk
Angela  Kamara
Robert  Keast
Christie  Keith
Beverly  Kerr
Mary  Kroeger
Raven  Fang
B.A.  Faris
Brian  Finde
Julie  Fitwin
David  Foeb
Roxane  Fovell
Ronnie  Fovich
Deborah  Maine
Forraine  Mann
Alan  Margolis
Margaret  Marshall

Alberto  Martinez
Polis

Fuyanda  Mavuya
Nicky  May
Junice  Melgar
Jose  Fuis  Mendoza
Elena  Metcalf
Faura  Miranda
Iris  Moore
Syema  Muzaffar

Papa  Djibril  Niang
Sandy  Niemann
Besem  Obenson

Deborah

Ottenheimer

Fauri  Paolinetti
Bill  Parer
Juana  Payva
Nimal  Perera

Fucille  Pilling  de
Fucena

Man  Poon
Jennifer  Potts
Paula  Quigley
Sumana  Reddy
Mary  Ann  Reiger

Marina  Rodriguez
Palma

Judith  Rogers
Forraine  Rothman
Sabala  and  Kranti
Shelly  Sala
Jason  Sanders
Shira  Saperstein
Merrie  Schaller
Katherine  Sear
John  Sellors
Katharine  Shapiro
Fonny  Shavelson
Theresa  Shaver
Mira  Shiva

Christine
Sienkiewicz

Jael  Silliman

Irene  Sotelo
Alvarez

Jennifer  Stonier
Susan  Sykes
Michael  Tan
Vijayalaxmi  Taskar
Joe  Taylor

Petra  ten  Hoope-
Bender

Carol  Thuman
Finda  Tietjen
Jan  Tritten
Greg  Troll
Mina  Tulugak
Faura  Turiano
Gilberte  Vansintejan
Elmar  Vinh-Thomas
Donna  Vivio

Claire  Von
Mollendorf

David  Werner
Sharon  Wilconson
Judith  Winkler
Merrill  Wolf
Juliana  Yartley
Karen  Zack
Fisa  Ziebel

Additionally,  the  incredible  patience  and  support  of  our  families  and  friends  during  the
long  process  of  producing  this  book  allowed  us  to  see  the  project  through.

Finally,  thank  you  so  much  to  the  individuals  and  foundations  who  financially
supported  this  project:  Allan  S.  Gordon  Foundation;  Anna  Falor  Burdick  Program  of  the
Falor  Foundation,  Inc.;  Averting  Maternal  Death  and  Disability  Program,  Heilbrunn  Center,
Mailman  School  of  Public  Health,  Columbia  University;  Compton  Foundation,  Inc.;
Conservation,  Food  and  Health  Foundation,  Inc.;  David  and  Fucile  Packard  Foundation;
Dorothy  and  Jonathan  Rintels  Charitable  Foundation;  Erik  E.  and  Edith  H.  Bergstrom
Foundation;  Ford  Foundation;  International  Confederation  of  Midwives;  Jadetree
Foundation;  Jeanne  Kemp;  Salt-Bush  Fund  of  the  Tides  Foundation;  Ruth  Sherer;  and  the
United  Nations  Population  Fund.

WWW

1 1* T

*1  HR'S}  MUM.  # II  or

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A Book  for  Midwives  (201  0)

How  to  use  this  book
Finding  information

To  find  information,  use  the  Contents,  the  Index,  or  the  Tabs.

The  Contents  at  the  beginning  of  this  book  list  the  name  of  each  chapter  in  the
order  in  which  it  appears.  Contents  of  each  chapter  are  also  listed  at  the  beginning
of  that  chapter.

The  Index,  or  the  yellow  pages  at  the  back  of  this  book,  lists  all  the  topics
covered  in  this  book  in  the  order  of  the  alphabet  (a,  b,  c,  d...).

Each  page  in  this  book  has  a number  at  the  bottom.  To  find  a chapter  or  topic
in  this  book,  find  it  in  the  contents  or  index,  and  then  turn  to  the  page  number
listed  next  to  it.

Tabs  on  the  right-hand  pages  separate  most  of  the  book  into  5 sections.

You  can  quickly  find  the  information  on  staying  healthy,  infection  prevention,
pregnancy,  labor  and  birth  (including  postpartum),  and  on  other  health  skills,
by  turning  to  the  sections  labeled  with  those  tabs.

Warnings,  medicines,  and  notes

Warnings,  medicines,  and  notes  are  separate  from  the  main  text.

Warning  boxes  show  very  important  information.  When  you  see  this  kind  of
box,  you  must  take  action  to  avoid  danger.

WARNING!  Do  not  insert  an  IUD  for  a woman  who  has
signs  of  infection.  The  infection  can  spread  to  the  womb.

Medicine  boxes  show  how  to  give  medicines.

Read  these  boxes  very  carefully,  and  always  look  in
the  green  medicines  pages  starting  on  page  463
before  giving  a medicine.

These  pictures  show  how
the  medicines  in  the  box
are  given  — in  this  case
as  tablets.  \

0

To  lower  a fever

• give  500  to  1 000  mg  paracetamol by  mouth,  every

4 to  6 hours.

Notes  show  information  that  is  useful,  but  not  directly  connected  with  the
information  around  it.

Note:  Clean  hands  do  not  stay  clean  for  long.  If  you  touch  anything
other  than  the  mother's  genitals,  you  must  wash  again.

A Book  for  Midwives  (201  0)

nesperian. ore

Understanding  pictures  of  the  body

How  we  show  the  outside  of  the  body

When  we  draw  a person,  we  try  to  draw  her  whole  body.  If  we  do  not  have  enough
room,  we  only  show  part  of  her  body.

If  it  is  important  to  see
the  baby's  head  and  the
vagina  more  clearly,  we
will  show  only  that  part
of  the  body,  so  we  can
make  the  picture  bigger.

This  picture
shows  a mother
pushing  her  baby
out  of  her  vagina.

How  we  show  the  inside  of  the  body

Sometimes  we  need  to  show  what  is  happening
inside  a woman's  body.  So  we  include  pictures  that
show  what  a woman's  body  would  look  like  if  you
could  see  inside  of  her.

Usually,  we  use  thick  lines  to  show  the  outside
of  a woman's  body,  and  thin  lines  or  dotted  lines
to  show  what  is  happening  on  the  inside.

the  womb,
inside  the
mother's  body

the  baby,
inside  the
womb

A note  on  language

Medical  and  technical  words  Throughout  this  book,  we  try  to  use  easily
understood  words  for  parts  of  the  body  and  things  that  the  body  does.  We  also
explain  the  medical  words  we  use.  If  there  is  a medical  or  technical  word  you  do
not  understand,  you  can  look  it  up  in  the  index  and  see  if  it  is  explained  in  the
book.  Or  you  can  look  in  the  glossary  on  page  503,  which  lists  some  medical  and
technical  words  that  are  useful  to  know.

He  and  she  When  talking  about  babies,  we  did  not  want  to  say  "he  or  she"  each
time  because  it  can  be  awkward.  So  sometimes  we  say  "she,"  and  sometimes  we
say  "he."

Getting  help

The  information  in  this  book  is  not  always  enough  to  help  you  solve  a health
problem.  When  this  happens,  get  help!  Depending  on  the  problem,  you  should:

Get  medical  advice.  A skilled  health  worker  or  doctor  should  be  able  to  help  you
decide  what  to  do.  This  is  not  usually  an  emergency.

Get  medical  help.  The  woman  or  her  baby  need  to  see  a skilled  health  worker  or
doctor  for  tests  or  treatment  as  soon  as  possible.

Go  to  a medical  center  or  hospital.  There  is  an  emergency.  Take  the  woman  or
her  baby  to  a hospital  right  away  for  surgery  or  other  immediate  help.

www. nespenan.org

A Book  for  Midwives  (201  0)

Contents

Introduction

Chapter  1:  Words  to  mid  wives

Learning  is  lifelong 1

Share  what  you  know 3

Respectful  and  compassionate  care  ....  6

Chapter  2:  Treating  health  problems

Finding  the  causes  of  health

problems 13

Finding  the  best  treatment 16

Chapter  4:  Helping  women  stay  healthy.

Eating  well 33

Caring  for  the  body  for  good  health  . . 42

Chapter  5:  Preventing  infection

Preventing  infection  saves  lives 49

Prevent  infection  by  keeping
germs  away 52

Clean  your  hands  and  wear
protective  clothing 53

PREGNANCY

Introduction

1

Work  to  improve  women's  health 8

Work  for  the  joy  of  it 11

12

Finding  root  causes  of
health  problems 21

Midwives  can  make  change 25

,26

29

32

Things  to  avoid  during
pregnancy  and  breastfeeding 45

48

Clean  the  space  and  bedding 57

Clean  and  sterilize  tools 59

Get  rid  of  wastes  safely 67

70

Chapter  3:  A woman's  body  in  pregnancy

A woman's  sexual  and  How  women  become  pregnant

reproductive  parts 27

Chapter  6:  Common  changes  in  pregnancy 72

Changes  in  eating  and  sleeping 73  Changing  feelings  and  emotions  ....  82

Body  changes  and  discomforts 76

Chapter  7:  Learning  a pregnant  woman's  health  history

Questions  in  a pregnancy
health  history 86

Does  she  have  signs  of  pregnancy? ...  86

How  pregnant  is  she  now?

When  is  the  baby  due? 88

Has  she  had  any  problems  with  past
pregnancies  or  births? 93

Malaria

HIV  and  AIDS

What  else  in  her  life  might  affect
her  pregnancy  and  birth?

Making  a transport  plan

..84

. 98
. 99

104

106

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A Book  for  Midwives  (201  0)

Chapter  8:  Prenatal  checkups

Talk  with  the  mother 109

Check  the  mothers  body 116

Check  for  signs  of  anemia 116

Weigh  the  mother 118

Check  the  mothers  temperature  ....  119

Check  the  mother's  pulse 120

Check  the  mother's  blood  pressure  . . 122
Check  for  signs  of  pre-eclampsia.  ...  125
Signs  of  bladder  or  kidney  infection.  .128

LABOR  AND  BIRTH

Introduction

108

Check  the  baby 130

Measure  the  mother's  womb 130

Find  the  position  of  the  baby 135

Listening  to  the  baby's  heartbeat.  ...  139

What  to  do  if  you  find
warning  signs  142

After  the  checkup 144

Record  of  prenatal  care 145

146

Chapter  9:  Getting  ready  for  labor  and  birth 1 48

Signs  that  labor  will  start  soon 149  What  to  bring  to  a birth 151

When  to  go  to  the  birth 151  Sterilize  your  tools  and  wash  up  ...  . 153

Chapter  1 0:  Giving  good  care  during  labor  and  birth

What  happens  during  labor  Be  ready  for  emergencies

and  birth 155  Keep  a record  of  what  happens

Care  for  the  mother  during  labor  ...  157  during  labor

Chapter  1 1 : Opening:  stage  1 of  labor

What  happens  during  stage  1 167

When  you  first  arrive 168

Helping  the  mother  relax  in  stage  1 . 169

Signs  for  the  midwife  to  check
in  stage  1 170

The  baby's  position 170

The  baby's  heartbeat 172

The  bag  of  waters 174

Chapter  1 2:  Pushing:  stage  2 of  labor

Watch  for  signs  that  stage  2 is  near

or  starting 195

What  happens  during  stage  2 197

Help  the  mother  have  a safe  birth  ...  199
Watch  for  warning  signs 202

154

163

164

166

The  mother's  pulse 178

The  mother's  temperature 178

The  mother's  blood  pressure 180

Bleeding  during  labor 183

Pain  in  the  womb 183

Watch  for  signs  of  progress 185

Safe  ways  to  encourage  labor 191

194

Help  the  mother  give  birth 206

Baby  is  breech 215

Delivering  twins 219

Baby  is  very  small  or  more  than
5 weeks  early 221

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Chapter  1 3:  The  birth  of  the  placenta:  stage  3 of  labor

..  222

Check  the  mothers  physical  signs . .

. 223

Help  her  push  out  the  placenta  . . . .

. 227

Bleeding  after  birth

. 224

Watch  for  bleeding  after  the

Watch  for  signs  the  placenta

placenta  is  born

. 236

has  separated

. 226

What  to  do  for  the  baby

. 240

Chapter  1 4:  The  first  few  hours  after  the

birth

..  246

What  to  do  for  the  mother

. 247

Breathing,  heartbeat,  temperature  . .

. 254

What  to  do  for  the  baby

. 252

The  baby's  body

. 256

General  appearance

. 253

Clean  up  and  answer  questions . . . .

. 267

Chapter  1 5:  The  first  weeks  after  the  birth

..  268

What  to  do  for  the  mother

. 269

Encourage  the  baby  to  breastfeed

Watch  her  womb  and  bleeding  ....

. 270

and  watch  how  she  grows

. 274

Watch  for  signs  of  womb  infection  .

. 271

Care  for  the  cord

. 277

Watch  for  signs  of  vaginal  infection

. 272

Look  for  signs  of  infection

. 277

What  to  do  for  the  baby

. 274

Watch  the  color  of  the  baby's  skin

and  eyes

. 279

Chapter  16:  Breastfeeding

Breast  is  best

. 281

Common  difficulties  while

..  280

How  to  breastfeed

. 282

breastfeeding

. 286

When  the  mother  works

Situations  that  affect  breastfeeding  .

. 291

outside  the  home

. 284

Alternatives  to  breastfeeding

. 294

HEALTH  SKILLS

Introduction 296

Chapter  17:  Family  planning 298

Choosing  a family  planning  method . 300  Making  family  planning  work  for

Chart:  family  planning  methods  ....  301  the  communitY 318

Chapter  1 8:  Sexually  transmitted  infections  (STIs) 320

What  are  STIs?

. . 321

Teaching  women  how  to

Discharge  from  the  vagina

. . 323

prevent  STIs

. 336

Sores  on  the  genitals

STIs  that  affect  the  whole  body  . . .

. . 329
. . 334

How  to  help  stop  STIs  in  your
community

. 337

Chapter  1 9:  Advanced  skills  for  pregnancy  and  birth

..  338

Vaginal  exams  during  labor

. . 339

Episiotomy

. 354

Home  methods  for  starting  labor  .

. . 341

Sewing  a tear  or  an  episiotomy  . . . .

. 356

Injections

. . 345

Caring  for  a woman  after  female

How  to  give  fluid  through  a vein  .

. . 350

genital  cutting  (circumcision) ....

. 367

Catheters

. . 352

Turning  a breech  or  sideways  baby  .

. 369

A Book  for  Midwives  (201  0)

www.hespenan.org

Chapter  20:  The  pelvic  exam:  How  to  examine  a woman's  vagina  and  womb.,

When  to  do  a pelvic  exam 374  The  speculum  exam

Before  the  exam 375  Tests  for  infections  and  cancer

The  visual  exam 376  The  bimanual  exam  (2-hand  exam) .

Chapter  21:  Howto  insert  an  IUD

Help  a woman  decide  if  the  IUD  Inserting  the  IUD

is  right  for  her 390  Afteryou  insert  tiiem|)

Before  you  insert  the  IUD 391  Removing  the  IUD

Chapter  22:  Helping  a woman  after  a pregnancy  ends  early

Problems  from  a pregnancy  Bleeding

that  ends  early 401  shock

Emergency  care  for  problems  after
miscarriage  or  abortion 406

Infection 409

Work  with  the  community  to
prevent  unsafe  abortions  . . .

Problems  with  the  MVA  ,
After  the  MVA

Working  with  medical  centers
and  doctors

Chapter  23:  Manual  vacuum  aspiration .

Deciding  when  to  do  MVA 418

Getting  ready  for  the  MVA 419

Doing  the  MVA 422

Chapter  24:  Getting  medical  help

What  medical  centers  and  hospitals
can  provide 433

Getting  to  a medical  center 438

Chapter  25:  Homemade  tools  and  teaching  materials

Low-cost  equipment 443  Teaching  materials

Medicines  (green  pages):  uses,  dosage,  and  precautions

When  to  use  medicines 463

How  to  take  medicines  safely 464

How  to  take  medicines 467

Kinds  of  medicine 470

Problem  index 472

Alphabetical  list  of  medicines

Oral  contraceptives

Medicines  for  HIV  and  AIDS  .

To  learn  more.

Technical  and  medical  words.

Index  (yellow  pages).
Due  date  calculator...

www. nespenan.org

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377

379

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388

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399

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A Book  for  Midwives  (201  0)

Midwives  and
community  health

For  thousands  of  years,  since  long  before
there  were  doctors  or  hospitals,  midwives
have  been  helping  women  stay  healthy,
helping  babies  into  the  world,  and  helping
families  grow.  Ask  a woman  why  she  prefers
the  care  of  a midwife  and  she  will  tell  you
that  midwives  are  knowledgeable,  patient,
and  respectful  of  her  traditions.

Why  are  midwives  such  important  and
valued  health  workers?

• Midwives  trust  in  the  safety  of  pregnancy  and  birth,  and  have
confidence  that  women  can  work  together  to  protect  their
own  health.

• Midwives  often  live  in  the  communities  they  serve,  so  the
families  they  help  know  and  trust  them.

• Many  midwives  spend  more  time  with  the  women  they  care
for  than  a doctor  or  clinic  worker  would.  This  helps  midwives
to  better  understand  women's  needs,  and  to  see  danger  signs.

• Most  midwives  are  women.  Many  women  feel  more
comfortable  talking  to  a woman  health  worker.

• Midwives  charge  lower  fees  than  most  doctors  or  hospitals  —
valuing  service  to  the  community  over  the  pursuit  of  money
or  power.

• In  poor  communities  where  there  are  few  health  services,
midwives  are  often  the  only  health  workers.

For  all  these  reasons,  in  most  of  the  world  midwives  are  the  first
and  sometimes  the  only  health  workers  women  go  to  for  help  in
birth  or  for  any  health  problem.  But  midwives  face  a number  of
challenges  in  this  important  work.

www.  nesperian. or

r

Challenges

Perhaps  the  biggest  struggle  for  midwives  (and  for  all  health
workers)  is  fighting  sickness  and  death  in  women  and  their  babies.
Every  year,  hundreds  of  thousands  of  women  die  in  pregnancy  and
during  labor.  Millions  more  are  injured  or  disabled.  Most  of  these
deaths  and  injuries  happen  to  women  who  are  poor  — who  do  not
have  enough  food,  or  safe  homes,  or  adequate  medical  care.

Most  of  the  midwives  of  the  world  live  in  poor  communities,
and  many  are  themselves  not  paid  a livable  wage.  The  people  of
each  community  must

I work  in  a restaurant  6 days
a week , and  then  go  home  to  care
for  my  family.  I’m  tired  all  the
time  and  my  husband  asks  me  to
stop  attending  births.

But  I continue  because
it  is  what  I am  good  at,
what  I love,  what  I am
called  to  do.

show  midwives  how
important  their  work  is
by  supporting  them  in
the  ways  that  they  can.

Local  governments  would
also  be  wise  to  invest  in
midwives.  These  governments
rarely  provide  midwives  with
adequate  education  or
supplies,  yet  they  rely  on
midwives  to  care  for  the  many
women  who  have  no  access  to
other  medical  care.

Along  with  being
underpaid,  midwives  may
struggle  to  receive  the  respect
they  deserve  for  their  work.

Doctors  and  others  too  often
dismiss  the  contributions  of
midwives.  When  midwives
are  not  treated  as  valued
health  workers  — part  of  a
community  of  health  care
providers  who  all  share  the
same  goals  — their  ability  to
care  for  women  is  hindered.

Midwives  may  actually  be  locked  out

of  the  health  system  when  a woman  who  has  a health  emergency  is
not  allowed  to  bring  her  midwife  with  her  to  the  hospital.

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"N

Traditional  midwives  (sometimes  called  TBAs)  face  particular
problems.  Many  professional  health  workers,  including
professional  midwives,  see  traditional  midwives  as  incompetent  or
old-fashioned.  These  traditional  midwives  may  be  very
knowledgeable  about  birth  and  skilled  with  plant  medicines,
gentle  massage  techniques,  or  other  safe,  effective  practices.  As
more  people  leave  their  villages  for  cities,  these  midwives  may  be
some  of  the  only  people  preserving  the  knowledge  and  customs  of
their  communities.  Traditional  midwives  often  work  for  little  or  no
pay,  but  instead  because  of  a belief  in  the  importance  of  their
work.  Like  other  midwives,  they  do  their  work  because  they  love
women  and  babies,  because  they  want  to  contribute  to  their
communities,  or  because  they  are  spiritually  called  to.

How  A Book  for  Midwives  can  help

Midwives  need  accurate  information  to  help  them  protect  the
health  and  well-being  of  women,  babies,  and  families.  They  need
strategies  to  fight  poverty  and  the  unequal  treatment  of  women,
and  for  working  together  and  with  other  health  workers  towards
health  for  all.  We  revised  A Book  for  Midwives  with  these  needs  in
mind.  In  this  edition  of  A Book  for  Midwives,  you  will  find:

• information  needed  to  care  for  women  and  their  babies
during  pregnancy,  labor,  birth,  and  in  the  weeks  following
birth,  because  this  is  the  primary  work  of  most  midwives.

• skills  for  protecting  a woman's  reproductive  health
throughout  her  life,  because  a woman's  health  needs  are
important  whether  or  not  she  is  having  a baby,  and  because

a woman's  health  when  she  is
not  pregnant  affects  how  healthy
and  safe  her  pregnancies
and  births  will  be.

v.

J

WWW.

A Book  for  Midwives  (201  0)

safe,  effective  methods  from  both  traditional  midwifery  and
modern,  Western-based  medicine,  because  good  health  care

in  labor  and  birth  uses

the  best  from  both

My  grandmother  is  a
midwife.  She  uses  plant
medicines  and  massage
to  help  pregnant  women.

Western  medicine  and
the  traditions  of  midwifery

• discussion  of  the  ways  that
poverty  and  the  denial  of
women's  needs  affect
women's  health,  and
how  midwives  can
work  to  improve  these
conditions,  because
changing  these
conditions  can  make
a lasting  improvement
in  health.

• suggestions  for  how
midwives  can  and  must
work  with  each  other,
with  other  health
workers,  and  with  the
larger  community,
because  working
together  strengthens
everyone's  knowledge
and  makes  action  to
improve  women's  health
more  effective.

The  basics  of  midwifery  care
will  never  change.  Women

and  families  will  always  need  compassionate  and  respectful  care
before,  during,  and  after  birth.  And  because  midwives  always
benefit  from  learning  more,  we  hope  that  the  expanded  and
updated  information  in  this  book  will  help  midwives  everywhere
learn  new  and  lifesaving  skills,  and  apply  those  skills  for  the
good  of  the  women,  babies,  and  families  they  serve.

I went  to  school  in  the  city
to  become  a midwife  myself }
and  I’ve  been  able  to  teach
my  grandmother  some  new
ways  to  sterilize  tools ,
watch  for  danger  signs ,
and  make  birth  safer.

7 C

But  I’m  still  learning
the  old  ways  from  her.

So  many  of  them  still  work
better  than  the  new  ways.

1 l it rfii  $±kt\*r

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A Book  for  Midwives  (201  0)

Chapter  1

Words  to  midwives

n this  chapter:

Learning  is  lifelong

Share  what  you  know

Share  what  you  know  with  other
health  workers  and  midwives 3

Respectful  and  compassionate  care

Do  not  judge 6

Follow  your  own  advice 6

Help  people  help  themselves 7

Work  to  improve  women's  health

People  who  affect  a woman's  health  ...  8
Men  can  care  for  women's  health 9

Work  for  the  joy  of  it

1

3

Share  what  you  know  with  the
community 4

6

Listen  more  than  you  talk 7

Talk  openly  about  difficult  subjects ....  7

Keep  things  private  (confidential) 7

8

Working  together  to  save  lives 10

11

i 1*  4li  i if  4 «r

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Words  to
midwives

To  work  for  the  health  and  well-being  of  women  and  babies  — that  is,  to  be
a midwife  — you  must  be  willing  to  learn,  to  treat  people  with  respect  and
compassion,  and  to  work  together  with  others  to  meet  the  health  needs  of
the  community.

Learning  is  lifelong

The  first  step  on  the  path  to  becoming  a midwife  — or  any  kind  of  health  worker
— is  learning  from  others.  And  even  the  most  experienced  midwives  continue  to
learn  and  gain  new  skills  throughout  their  whole  lives.

Midwives  learn  from  experience  and  from  books  and  classes.  Each  way  of
learning  is  important.  All  midwives  should  find  a balance  between  study  and
practice.

Books  and  study  help  midwives
understand  a broad  range  of
information.

But  practice  is  the  only  way  to  learn
the  skills  needed  to  care  for  women
and  babies.

www.iicspcrian.org

1

Chapter  1:  Words  to  midwives

Experienced  midwives  continue  to  learn

There  is  always  more  to  know  about  birth  and  about  health.  Every  birth  is
different,  medical  information  changes,  and  there  are  new  skills  to  be  learned.
As  long  as  you  are  a midwife  you  can:

• watch  how  other  midwives,
health  workers,  and  doctors  do
things.

• ask  the  women  and  families  you
work  with  what  they  like  and  do
not  like  about  the  care  that  you
give.

• read  books  or  other  written
materials.  Keep  helpful  books
with  you  so  you  can  look  up
information  you  do  not  use
regularly  or  remember.

• learn  new  skills.  If  you  can  get
the  training  and  tools  to  do  new
procedures  safely,  do  not  be
afraid  to  learn  a new  skill.  This
will  allow  you  to  help  more
women  in  your  community  and
to  become  a better  midwife.

Midwives  learn  from  teachers,  books,  and  other  midwives  and  health  workers.
Mostly  they  learn  safe  ways  to  practice.  But  as  any  midwife  gains  more  experience,
she  will  discover  that  some  of  what  she  learned  is  not  the  safest  or  most  effective
way  to  care  for  women.

Midwives  must  be  willing  to  change  their  ideas  when  they  learn  new  ways  of
practicing  so  they  are  always  practicing  in  the  best  ways  they  can.  Midwives  must
look  honestly  at  the  ways  they  practice  to  be  sure  they  are  working  well  —
whether  they  learned  these  practices  from  doctors,  traditional  healers,  or
anyone  else.

Asking  "why?"

Asking  "why"  is  important  because  it  helps  you  do  more  than  just  remember  what
you  have  been  told  or  what  you  have  read.  When  you  know  why,  you  can  make
decisions  even  when  there  is  no  person  or  book  to  tell  you  exactly  what  to  do.  You
can  also  adapt  a treatment  or  tool  to  be  of  use  in  a way  that  others  may  not  use  it.
Finally,  asking  "why"  is  important  for  understanding  the  causes  of  problems  —
to  treat  problems  effectively,  and  to  prevent  them  from  happening  again.

A Book  for  Midwives  (201  0)

www.  Hesperian. ore

Share  what  you  know

Share  what  you  know

Along  with  learning  from  books  and  teachers,  midwives  learn  much  of  what  they
know  from  each  other  and  from  the  families  they  care  for.  And  midwives  can
improve  health  by  sharing  what  they  know  with  the  community.

Share  what  you  know  with  other  health  workers
and  midwives

Midwives  can  work  together  to  help  each  other.  If  one  midwife  becomes  sick  or
cannot  work,  another  midwife  can  help  the  women  she  was  caring  for.  Midwives
can  also  learn  from  and  teach  each  other.  In  some  communities,  midwives  and
other  health  workers  share  information  with  each  other,  talking  honestly  about
their  work.  Some  midwives  come  together  to  meet  every  few  months,  compare
information,  and  share  resources.  At  midwife  meetings  you  can:

• take  turns  telling  stories  about  births  you  have  attended.

Be  sure  to  share  the  difficult
births  and  mistakes.

Admitting  mistakes  is
difficult,  but  it  is  a great  gift
when  there  is  an  opportunity
to  learn  from  them.  Other
midwives  can  explain  what
they  would  have  done  the
same  or  differently.  To  protect
the  mother's  privacy,  do  not
share  her  name.

Next  time  I’ll  check  a
woman’s  temperature  during
labor.  Then  I can  find  an
infection  earlier.

• ask  other  health  workers  to  come  meet  with  your  group.  For  example,  an
herbalist  could  come  talk  about  local  plants  that  can  fight  infections.  Or  a
midwives  group  could  talk  with  nurses  from  a local  maternity  center  about
how  midwives  and  nurses  can  work  together.

• share  educational  books  (including  this  one!)
with  other  midwives.  If  no  one  has  much  money,
perhaps  a group  of  midwives  can  put  their  money
together  to  buy  a book  to  share.

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3

Chapter  1:  Words  to  midwives

• practice  helping  women  with  different  problems  by  acting  them  out
(role  play).  For  example,  one
person  can  pretend  to  be  a
pregnant  woman  who  is  not
eating  enough  healthy  food.

Another  person  can  pretend  to  be
her  midwife  — listening  and
giving  advice.  Afterwards,  each
actor  can  explain  how  she  felt,
and  the  others  in  the  group  can
offer  suggestions  for  what  they
would  do  differently.  Make  sure  everyone  has  a chance  to  play  one  of  the  roles.

• make  use  of  different  midwives'  skills.  If  one  midwife  knows  how  to  read,
she  can  read  aloud  from  books  to  the  other  midwives.  A midwife  who  knows
how  to  sterilize  tools  can  teach  the  others  in  the  group.

Share  what  you  know  with  the  community

As  a midwife,  you  give  advice,  treat  problems,  even  save  lives.  But  the  overall  health
of  those  around  you  is  not  in  your  hands  alone.  In  part,  this  is  because  people
decide  for  themselves  how  to  eat,  how  to  do  their  work,  and  what  choices  they
make.  By  teaching  and  sharing  information,  midwives  can  help  people  to  make
their  own  choices  more  wisely.  This  is  why  your  first  job  as  a midwife  is  to  teach.

Teaching  can  happen  anywhere  and  anytime.  During  a checkup,  when  you
explain  to  a woman  why  you  are  asking  each  question,  you  are  teaching  her.  When
you  show  a woman's  husband  why  family  planning  is  his  responsibility  too,  you
are  teaching  him.  Even  at  the  market,  at  a community  gathering,  or  anytime  you
meet  with  others,  you  have  the  chance  to  teach.

Teaching  classes

There  are  probably  topics  that  many  people  in  the  community  could  benefit  from
learning  about.  If  possible,  call  meetings  for  pregnant  women,  families,  or  other
community  members  to  teach  about  health  and  birth.  You  can  teach  about:

• how  the  body  works.

• how  to  choose  and  use  family  planning.

• how  to  eat  and  care  for  yourself  in  pregnancy.

• how  to  have  a safer  birth.

• how  to  care  for  yourself  after  a birth  and  how  to  breastfeed.

Teaching  is  a skill,  and  it  takes  practice.  A good  place  to  start
is  by  listening.  When  you  find  out  what  people  already  know,
you  can  help  them  build  on  that  knowledge.  And  when  you
listen,  you  will  learn  from  those  you  are  teaching.

Your  ears  are
2 of  your  most
important
tools.

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A Book  for  Midwives  (201  0)

Share  what  you  know

For  example,  if  a group  of  women  wants  to  learn  about  sexually  transmitted
infections  (STIs),  you  can  first  ask  each  person  to  share  what  she  knows  about  STIs.
Women  may  know  about  STIs  from  books  or  classes,  from  talking  to  other
women,  or  from  having  had  infections  themselves.

After  people  have  shared  their  knowledge,  find  out  what  questions  they  have.
People  in  the  group  may  be  able  to  answer  each  others  questions.  You  can
probably  add  some  important  medical  information  and  point  out  when  people
have  incorrect  beliefs  too.  By  encouraging  the  group  to  talk,  you  find  out  what
they  really  need  to  know  — and  help  them  understand  how  much  knowledge  they
already  have.  A person  who  feels  confident  that  she  understands  a problem  is  more
able  to  work  to  solve  it.

Show  respect  for  the  people  you  teach,  and  be  sure  that  what  you  say  is
meaningful  to  their  lives.

• Sit  in  a circle  with  everyone  on  the  same  level.  This  puts  you  in  the  same
place  as  everyone  else,  and  shows  that  you  are  not  the  only  one  with
knowledge.

• Be  prepared.  Think  about  what  you  want  to  share  before  you  start  teaching.

• Use  many  methods  to  teach.  People  learn  differently,  and  everyone  learns
better  when  they  learn  the  same  thing  in  different  ways.  After  you  talk  with
the  group  about  STIs,  the  group  could  act  out  a play  about  them.  Or  make
posters  about  STIs  to  share  with  the  community.

You  all  said  you  want  to
learn  about  what  to  eat
during  pregnancy  and
after  the  baby  comes.
What  do  you  know  about
healthy  eating  now?

I’ve  heard  you
should  not  eat
meat  when  you  are
breastfeeding.  It
will  harm  the  baby.

That’s  not  true!
You  need  to  eat
meat  to  make  the
blood  strong!

Asking  questions  will  help  you  understand  what  people  already
know,  what  they  want  to  learn,  and  what  obstacles  they  face.

Remember,  some  people  are  used  to  speaking  up  in  groups.  Others  may  be
afraid.  Encourage  women,  those  who  have  little  schooling,  or  anyone  who  usually
keeps  quiet  to  share  his  or  her  thoughts.  For  more  ideas  on  how  to  teach  so  people
can  truly  learn,  see  Helping  Health  Workers  Learn.

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Chapter  1:  Words  to  midwives

Share  your  knowledge  with  the  people  you  care  for

With  accurate  information,  each  woman  has  the  ability  to  understand  her  body
and  to  make  wise  decisions  about  her  health.  Each  time  you  meet  with  a woman
during  pregnancy  or  for  other  care,  explain  what  you  are  doing  and  why.  Answer
any  questions  the  woman  has  about  her  body  or  her  health.

Admit  what  you  do  not  know

No  one  knows  every  answer.  Some  problems  have  no  easy  answer!  Admit  what
you  do  not  know,  and  people  will  trust  the  knowledge  you  do  have.

I worried  about  you
when  you  did  not
come  last  month.
Was  something
wrong?

Respectful  and  compassionate  care

Everyone  deserves  to  be  treated  with  respect.  As  a
health  worker,  the  way  you  treat  a woman  is
particularly  important.

Midwives  are  often  trusted
authorities.  A kind  or
encouraging  word  from  you
can  go  a long  way  in  giving  a
woman  confidence  in  her
ability  to  care  for  herself.  An
unthinking  or  cruel  remark  can  cause
hurt  that  lasts  many  years  in  a woman.

Do  not  judge

Some  women  are  used  to  being  treated
disrespectfully.  When  you  begin  to  work  with
a woman  who  is  often  treated  with  disrespect
because  of  her  age,  the  work  she  does,  her
ethnicity  or  religion,  how  much  money  she

has,  having  a disability,  or  for  other  reasons,  she  may  expect  you  to  treat  her  badly
as  well.  You  can  only  overcome  this  fear  by  showing  her  that  you  are  there  to  listen
and  help  her  — not  to  judge  or  criticize.

Follow  your  own  advice

People  are  more  influenced  by  what  you  do  than  what  you  say.  And  because
midwives  are  respected  by  their  communities,  the  things  you  do  may  encourage
others  to  care  for  themselves.  If  you  breastfeed  your  children,  other  women  in  the
community  may  be  more  likely  to  breastfeed.  If  you  do  not  smoke,  other  women
may  follow  your  example  and  not  smoke,  or  may  stop  smoking.  Live  your  own  life
as  you  would  advise  others  to  do.

A Book  for  Midwives  (201  0)

www. nesperian.org

Respectful  and  compassionate  care

Help  people  help  themselves

Everyone  has  the  right  to  decide
what  happens  to  her  own  body.

And  people  can  and  should
take  the  lead  in  their
own  care.  In  this  way,
they  can  become  —

actively  responsible  ~~  / / —

r i • iii  WA'

tor  their  own  health
and  the  health  of
their  communities.

Listen  more  than  you  talk

A woman  often  needs  someone  who  will  listen  to  her  without  judgment.  And  as
she  talks,  she  may  find  that  she  has  some  of  the  answers  to  her  problems.

Talk  openly  about  difficult  subjects

Some  women  feel  shy,  ashamed,  confused,  or  private  about  their  problems.  This  is
especially  common  with  family  problems  and  sex.  A midwife  who  talks  honestly
and  openly  about  these  subjects  will  discover  that  many  women  share  the  same
problems.  By  speaking  directly  and  comfortably  to  women  about  their  families,
sexuality,  and  sexual  health,  you  will  help  women  feel  less  alone,  and  you  may
help  them  solve  problems  that  have  a large  effect  on  their  health.

Keep  things  private  (confidential)

Never  tell  anyone  about  someone  else's  health  or  care  — unless  the  person  says  it
is  OK.  And  when  you  talk  to  women  about  their  health,  do  it  in  a private  place
where  others  cannot  hear.

In  particular,  respect  a woman's  privacy  about  subjects  that  may  be  sensitive  to
her,  such  as  sexually  transmitted  infections,  miscarriages  and  abortions,  and

family  problems.  You  should  never  share
this  type  of  information  without  a
woman's  permission.

There  is  only  one  time  when  it  is  OK
to  share  information  about  someone's
health:  if  another  health  worker  is  caring
for  the  woman  during  an  emergency,
the  health  worker  will  need  to  know  the
woman's  health  history  in  order  to
provide  safe  and  effective  care.

A midwife  must  keep  what  she
knows  about  a woman  private.

I will  never  tell  ^
anyone  what
youve  shared
with  me.

Thank  you.  It's
a relief  to  be
able  to  speak
freely.

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Chapter  1:  Words  to  midwives

Work  to  improve  women's  health

Midwifery  is  not  just  about  treating  health  problems  as  they  arise.  Health  problems
have  many  causes.  Some  are  physical,  some  are  social,  economic,  or  political.

By  treating  social,  economic,  and  political  causes,  you  can  prevent  many  health
problems  — and  protect  more  women  in  the  community.

Working  to  treat  social  causes  and  to  improve  women's  health  is  not  something
one  midwife  can  do  alone.  She  must  work  with  the  whole  community.
Understanding  causes  and  finding  solutions  is  more  possible  when  people  work
together.  See  page  23  for  ideas  about  working  with  others  to  make  change.

People  who  affect  a woman's  health

A woman's  health  is  affected  by  many  people.  To  care  for  a woman,  you  must  work
with  those  people  too.

Some  of  the  people  that  affect  a woman's  health  are:

• her  husband,  children,
parents,  and  other  family
members.

• the  people  she  works  with,
or  works  for.

• her  neighbors  and  friends.

• community  leaders  —
including  spiritual  leaders,
government  officials,  and
village  heads.

• other  health  workers  —

like  traditional  healers,  doctors,
and  community  health  workers.

A woman's  health  can  be
protected  — or  hurt  —
by  the  whole  community.

Anyone  who  influences  the  way  a woman  works,  eats,  has  sex  (or  does  not
have  it),  or  cares  for  her  daily  needs  has  an  effect  on  a woman's  health.  Sometimes
the  effect  is  good  — it  protects  or  improves  the  woman's  health.  Sometimes  it  is
bad  — the  woman's  health  and  well-being  are  endangered.

For  example,  it  may  not  help  to  tell  a pregnant  woman  to  eat  more  if  her
husband  always  eats  first  and  there  is  not  enough  left  for  her.  She  herself  may
believe  her  husband's  and  children's  hunger  is  more  important  than  her  own.

Who  else  could  you  involve  to  try  to  improve  a woman's  nutrition,  when  she
does  not  have  enough  to  eat?

• the  woman's  husband,  who  is  eating  first.  Perhaps  you  could  talk  to  him
about  how  much  food  a pregnant  woman  needs.

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Work  to  improve  women's  health

• the  men  of  the  community,  who  all  expect  to  eat  first.  The  woman's  husband
may  be  more  likely  to  change  if  other  men  do  too.  You  could  have  a meeting
of  men  and  women  and  discuss  why  pregnant  women  must  eat  more  to  be
healthy.  If  one  man  in  the  community  agrees  that  women  must  have  as  much
or  more  healthy  food  as  men,  this  opens  the  door  for  others.

• children,  who  will  soon  grow  up  to  be  mothers  and  fathers.  Each  time  a man
eats  first  and  most,  and  a woman  eats  last  and  least,  their  children  see  and
learn  that  a man's  hunger  is  more  important  than  a woman's.  By  talking  to
groups  of  schoolchildren  or  by  changing  the  way  your  own  family  eats,  the
next  generation  may  grow  up  to  value  men  and  women  more  equally.

Who  could  you  involve  to  make  sure  there  is  enough  food  for  everyone?

Men  can  care  for  women's  health

Whenever  you  can,  encourage  men  to  be  partners  in  improving  women's
health.  Husbands,  fathers,  sons,  community  leaders,  spiritual  leaders,
bosses,  and  other  men  all  play  a role  in  how  healthy  women  will  be.  If
the  men  of  the  community  feel  responsible  for  the  health  of  women,  the
whole  community  will  benefit.  Midwives  can  help  men  be  involved.

Build  on  the  roles  and  skills  that  men  already  have.  For  example,  in
many  communities  men  are  seen  as  protectors.  Help
men  learn  how  to  protect  the  health  of  women.

Encourage  men  to  share  the  responsibilities  of
pregnancy  and  parenting.  Men  can  care  for  children  in
the  same  ways  that  women  do:  comforting,  bathing,
feeding,  teaching,  and  playing  with  them.

Invite  women  and  men  to  community  meetings,
and  encourage  women  to  speak  up.

Work  with  men  who  are  sympathetic  to  women's  needs.  They  can  talk
to  other  men  who  listen  more  closely  to  a man  than  to  a woman.

Give  practical  suggestions.  Men  who  care  very  much  about  the  health
of  women  in  their  lives  may  not  know  where  to  start.  For  example:

• Tell  men  how  they  can  get  tested  and  treated  for  sexually
transmitted  infections.  If  only  a woman  is  treated,  she  will  quickly
be  infected  again  by  her  partner.

• Explain  to  a man  that  his  pregnant  wife  needs  help  with  her
daily  work.

• During  labor,  show  a man  how  and  where  to  rub  a woman's  back
to  relieve  her  pain.

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9

Chapter  1:  Words  to  midwives

Working  together  to  save  lives

When  midwives  work  with  the  whole  community,  they  can  find  solutions  to
help  the  women  they  care  for  — or  to  help  everyone  in  the  community.  Here  is
a true  story:

A creative  solution

In  the  small  villages  of  West  Africa,  when  a woman  has  a problem  in  labor,
it  is  very  hard  for  her  to  get  to  a hospital.  Few  villagers  have  cars,  and  most
taxi  drivers  refuse  to  take  women  in  labor.  When  a woman  is  in  danger,
there  is  little  her  midwife  can  do.

Some  midwives  and
villagers  talked  about  this
problem,  and  discovered  a
creative  solution.  Even
though  no  villagers  had
cars,  they  were  near  a large
road.  All  day  and  night,
trucks  drove  down  the
road  bringing  products  to
the  city.  Someone
suggested  that  if  a woman
needed  help  in  labor,  she
could  ride  with  a truck
driver  to  the  hospital.

For  this  plan  to  work,  the  villagers  needed  to  be  sure  that  truck  drivers
would  agree  to  stop  if  they  were  needed.  They  talked  to  someone  from  the
union  of  truck  drivers.  The  union  members  were  happy  to  help,  and  now
they  have  a system  that  is  simple  and  effective.

When  a woman  needs  to  go  to  the
hospital,  the  midwife  puts  a yellow  flag
out  near  the  road.  When  a passing  truck
driver  sees  the  flag,  he  stops  and  picks
up  the  woman  and  the  midwife,  and
takes  them  to  the  city  hospital.

By  working  together  with  each  other,
other  villagers,  the  truck  drivers,  and
their  union,  these  midwives  helped
save  lives.

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A Book  for  Midwives  (201  0)

Work  for  the  joy  of  it

Work  for  the  joy  of  it

If  you  want  other  people  to  take  part  in  improving  their  lives  and  caring  for  their
health,  you  must  enjoy  such  activities  yourself.  If  not,  who  will  want  to  follow
your  example?

Most  midwives  do  their
work  out  of  love  and  as  a
service  to  the  community.

Although  their  work  has
great  value,  midwives  are  rarely
paid  much  (a  sad  truth  for  many
health  workers  and  women  workers  in
general).  Even  so,  a midwife  who  works
hard  and  puts  the  needs  of  her
community  first  will  usually  be
respected  and  appreciated  by  the

people  she  serves.  ^ ^

You  may  or  may  not  be  paid  for  your  work,  but  never  refuse  to  care  for
someone  who  is  poor  or  cannot  pay.  Everyone  deserves  your  full  care  and
attention.

The  work  of  a midwife  is  often  difficult.  Midwives  work  long  hours,  lose  sleep,
strain  their  bodies,  and  challenge  their  minds.  Midwives  feel  an  intense
responsibility  that  can  cause  stress  or  deep  emotional  pain.  For  most  midwives,
these  challenges  are  all  worth  facing,  because  the  work  of  a midwife  is  also  so
rewarding.  Teaching  women  and  families  about  their  bodies  and  health,  treating
serious  health  problems,  and  helping  welcome  new  lives  into  the  world  are  some
of  the  most  important  and  rewarding  tasks  anyone  can  do  in  their  lives.  Our  world
needs  the  valuable  work  of  midwives  because  midwives  make  this  world  stronger,
healthier,  and  safer.

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A Book  for  Midwives  (201  0)

Chapter  2

Treating  health  problems

In  this  chapter:

Finding  the  causes  of  health  problems

Finding  the  best  treatment

Benefits  and  risks 16  Know  your  limits,

Types  of  medicine 17

Finding  root  causes  of  health  problems

Make  change  in  your  community  to
prevent  health  problems 23

Midwives  can  make  change

13

16

20

21

25

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12

Treating  health
problems

Most  of  the  daily  work  of  a midwife  is  treating  health  problems.  When  a woman
you  are  caring  for  has  a problem,  like  exhaustion,  pain  in  the  belly,  or  even
heavy  bleeding,  you  will  need  to  take  these  steps  to  solve  it:

1.  Find  the  immediate  cause  of  the  problem.

2.  Choose  the  best  treatment.

3.  Look  for  the  root  (underlying)  causes  of  the
problem  — to  fully  address  the  problem  or  prevent
problems  from  happening  again.

Finding  the  causes  of  health  problems

In  this  section,  we  tell  how  Celeste,  a midwife,  solves  a health  problem.  The  details
of  this  story  apply  only  to  Celeste,  but  the  way  she  thinks  about  the  problem  and
works  to  solve  it  can  be  used  by  any  midwife  for  any  health  problem.  We  list
each  step  that  Celeste  uses  so  that  you  can  use  these  steps  too.

1.  Start  with  a doubt.  This  means  start  by  admitting  what
you  do  not  know.

2.  Think  of  all  the  possible  causes.  Most  ways  of  feeling
sick  can  be  caused  by  many  different  problems.

3.  Look  for  signs  to  find  the  likely  cause.  Health  problems
have  signs.  You  can  see  these  signs  in  how  someone
feels,  how  their  body  looks  and  acts,  and  by  taking
medical  tests.

4.  Decide  the  most  likely  cause.

5.  Make  a plan  for  what  to  do.  This  could  be  a plan  to  change  a person's
habits,  change  something  in  their  home  or  environment,  or  give  a medicine.

6.  Look  for  results.  Find  out  if  your  treatment  is  working.  If  it  is  not,  start  these
steps  again.

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Chapter  2:  Treating  health  problems

Celeste's  steps  for  finding  causes

1.  Start  with  a doubt.

A young  pregnant  woman  named  Elena  came  to  her  midwife,  Celeste,
for  care.  During  the  checkup,  Elena  said  that  she  felt  tired  all  the  time.

First,  Celeste  acknowledged  that  she  did  not  know  what  was  making
Elena  tired.

3.  Look  for  signs  to  find  the  likely  cause.

Celeste  asked  Elena  questions  to  find  out  more  about  the  tired  feeling.

Are  you
working  more
than  usual?

Are  you
sleeping  less?
Do  you  feel  ill?

I work  hard [
but  no  harder
than  usual.

Vm  sleeping
enough , and  do
not  feel  ill.

Celeste  also  asked  Elena  what  she  usually  ate.  Elena  said  that  she
mostly  ate  maize  and  beans  every  day.  Actually,  mostly  just  maize.
Elena  complained  of  the  high  cost  of  buying  meat.

Celeste  checked  Elena's  physical  signs.  Elena  had  pale  eyelids  and
gums  and  a fast,  weak  pulse  — all  signs  of  anemia.

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A Book  for  Midwives  (201  0)

Finding  the  causes  of  health  problems

4.  Decide  the  most  likely  cause.

Celeste  could  not  do  a blood  test  to  be  sure,  because  there  was  no
laboratory  nearby,  but  all  the  other  signs  showed  that  Elena  probably
had  anemia.

5.  Make  a plan  for  what  to  do.

Celeste  explained  to  Elena  that  anemia  can  cause  tiredness  and  make  it
hard  for  a woman  to  recover  after  a birth  — especially  if  the  woman
bleeds  heavily.  She  told  Elena  that  anemia  means  not  enough  iron  in  the
blood  and  that  it  can  usually  be  cured  by  eating  foods  rich  in  iron  and
protein  or  by  taking  iron  pills.

6.  Look  for  results.

When  Elena  came  back  for  her  next  check  up,  Celeste  checked  for  signs  of
anemia.  After  improving  her  diet,  Elena  seemed  be  getting  better.  If  Elena
had  not  gotten  better,  Celeste  would  have  recommended  that  Elena  take
iron  and  folate  pills.

These  6 steps  will  help  you  solve  most  health  problems.

Note:  To  "start  with  a doubt"  is  very  difficult  for  most  health  workers.
Many  health  workers  are  afraid  to  admit  when  they  do  not  know  an
answer.  But  to  accurately  assess  a problem,  and  to  treat  it
appropriately,  we  must  admit  what  we  do  not  know.

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15

Chapter  2:  Treating  health  problems

Finding  the  best  treatment

When  you  treat  any  health  problem,  from  anemia  to  too-long  labor
to  heavy  bleeding,  you  must  find  the  treatment  that 1
most  benefits  and  the  least  risk  of  harm.

Benefits  and  risks

Any  time  you  make  a decision  about  a medical
treatment,  you  should  consider  the  benefits  and
risks.

A benefit  is  the  good  that  an  action  or

treatment  might  bring.  A risk  is  the  harm  that  it
might  cause.  Each  time  you  make  a decision,  try
to  choose  the  action  with  the  most  benefit  and
the  least  risk.

When  the  benefits  "weigh'
more  than  the  risks,  an
action  is  worth  doing.

Think  again  about  Elena  and  Celeste:

What  if  Elena's  anemia  did  not  go  away  after  eating

more  iron-rich  foods  and  taking  iron  pills?  She  and
Celeste  would  have  to  make  a difficult  decision.

Celeste  knows  that  a woman  with  severe  anemia  is  probably  safer  giving  birth
in  a well-equipped  medical  center  than  at  home.  This  way,  if  severe  bleeding
happens,  a blood  transfusion  is  immediately  available.  Without  this  care,  Elena
might  be  very  weak  after  the  birth.  This  weakness  will  make  her  more  likely  to  get
an  infection.  It  will  make  it  very  hard  for  her  to  care  for  her  family  and  herself.  And
if  a baby's  mother  is  not  able  to  care  for  him  well,  he  may  be  in  danger  too.

On  the  other  hand,  most  women  in  the  village  have  anemia.  And  most  of  them
will  not  have  serious  problems  after  their  births.  The  hospital  is  a day's  journey
away  and  very  expensive.  Elena's  family  would  have  to  spend  most  or  all  of  their
money  for  her  to  give  birth  there.

Staying  home  and  going  to  the  hospital  each  have  benefits  and  risks.  What
would  you  do?

Medicines  in  particular  have  both  benefits  and  risks.  Even  a medicine  that  is
very  helpful  for  treating  a health  problem  may  have  side  effects  or  dangers.  In  this
book,  there  are  procedures  and  medicines  that  have  very  serious  risks.  We  include
them  because  when  they  are  truly  necessary,  they  can  save  lives.  But  before  giving
any  medicine  or  doing  any  invasive  (inside  the  body)  procedure,  including
emergency  procedures  like  removing  the  placenta  by  hand  (page  230)  or  MVA
(page  416),  you  must  decide  if  you  can  do  it  safely  — with  more  benefit  than  risk.

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WWW.

Finding  the  best  treatment

I am  going  to  have  to
reach  inside  to  get
the  placenta  out.

Yes , very!  But  the  road  is
washed  out  by  the  rain  — and
there  is  no  way  to  get  help
before  she  bleeds  to  death.

Types  of  medicine

Around  the  world,  people  use  many  different  ways  of  healing:

• Traditional  medicine  (also  called  folk  medicine):  These
ways  of  healing  have  been  passed  down  from  older  healers
to  younger  ones  for  many  generations.  Traditional  ways  of  healing  use
massage,  plant  medicines,  and  communication  with  the  spiritual  world.

Traditional  medicines,  particularly  home  remedies,  can  be  very  effective.

They  are  often  the  safest,  easiest,  and  least  costly  treatments  for  most  health
problems.  And  when  money  runs  out,  or  outside  aid  groups  leave,  the  plants,
massage  techniques,  and  other  traditional  ways  of  healing  will  still  be  here.

Many  traditional  medicines  have  been  tested  using  science.  Testing  has  shown
that  some  traditional  medicines  work  well  and  others  do  not,  or  they  only
work  because  people's  belief  in  them  is  strong.  Some  traditional
medicines  are  harmful  or  dangerous.

• Western  medicine:  This  system  of  healing  relies  on  scientific  testing,  Q ©
manufactured  medicines  (drugs),  and  surgery  to  treat  health  problems.

• Non-Western  systems  like  acupuncture,  ayurveda,  or  homeopathy:

These  systems  of  healing  may  have  been  used  for  thousands  of  years,

are  taught  in  books  and  schools,  and  may  have  been  tested  using  science.
Many  of  these  systems  also  use  plant  medicines.

One  person  may  use  several  of  these  ways  of  healing.

There  is  not  enough  space  in  this  book  to  fully  describe  every  system  of  healing.
What  is  important  to  remember  is  that  each  type  of  healing  has  benefits,  and  that
any  kind  of  medicine  must  be  used  with  care.

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Chapter  2:  Treating  health  problems

Western  medicine

Western  medicine,  when  used  correctly,  can  save  lives.  And  Western  medicine  is
usually  the  best  treatment  for  emergencies.  For  example,  when  a woman  is
bleeding  heavily  after  a birth,  there  may  be  plant  medicines  in  your  area  that  can
slow  her  bleeding.  But  Western  medicines  often  work  better  and  more  quickly  —
they  are  more  sure  to  save  a bleeding  woman's  life.

Use  Western  medicines  correctly

Most  Western  medicines  have  been  carefully  tested  by  science.  Western  medicine  is
usually  very  effective  at  treating  problems.  But  Western  remedies  are  often
expensive,  some  have  side  effects,  and  in  many  cases  they  are  not  necessary.  Most
basic  health  problems  could  be  treated  just  as  well  with  traditional  or  home
remedies,  or  just  by  waiting.

Don't  you
think  he

needs  an

injection?  J

yW(  m

M\\

Using  any  medicine  when  it  is  not  necessary,  or  using  too  much,  can  cause
serious  health  problems.  For  example,  some  people  believe  that  only  an  injection
will  help  them  when
they  are  sick.  These
people  would  usually
get  better  if  they  did
nothing,  and  in  many
cases,  unnecessary
injections  have  caused
abscesses  or  have  passed
disease  (like  HIV)  when
given  with  unsterilized
needles.  So  although
medicines  can  save  lives,

they  must  be  used  Take  time  to  explain  why

correctly.  medicines  are  not  needed.

No.  All  he  has  is
a cold.  Let  him
rest , give  him
good  food  and
lots  to  drink.
Strong  medicine
won't  help  and
might  even
harm  him.

This  book  is  mostly  about  Western  medicine

This  book  mostly  teaches  how  to  use  Western  methods  of  healing.  There  is  one
main  reason  for  this:  Western  medicines  are  available  in  most  parts  of  the  world.
We  do  not  know  enough,  nor  do  we  have  enough  room  to  explain  how  to  use  the
millions  of  traditional  plants  and  ways  of  healing  that  are  used  around  the  world.
Therefore,  please  use  the  back  of  this  book  to  write  down  the  traditional  methods
that  you  use.  And  if  you  translate  or  adapt  this  book,  be  sure  to  include  your  local
ways  of  healing.  It  is  very  important  to  share  these  traditional  ways  of  healing  so
that  they  are  not  forgotten!

WWW.

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Finding  the  best  treatment

I make  a tea  from  this
plant  It  always  seems  to
help  when  labor  is  slow.

Choosing  a medicine  that  is  safe  and  helpful

Before  you  give  a medicine
(traditional  or  Western),  you
should  be  confident  that  it  is  safe
and  helpful.  To  know  if  this  is  true,
think  about  (and  ask  others)
these  questions:

• What  is  it  used  for?

• What  happens  when  you  use  it?

• How  often  does  it  help  make  a problem  better?

• What  side  effects  or  other  problems  does  it  cause?

When  you  are  trying  a treatment  for  the  first  time,
use  it  alone,  not  mixed  with  other  treatments.  That  way
you  will  know  if  it  works,  and  if  it  causes  problems.

See  page  463  to  learn  more  about  using  medicines  safely.

Thanks!
But  does  it
cause  any
problems?

Medicine  and  greed

Sadly,  some  healers  and  health  workers  are  motivated  by  greed.  In  order  to  make
money,  they  may  recommend  a treatment  that  is  not  necessary,  that  does  not  work,
or  even  one  that  is  dangerous.  Some  healers  rely  on  the  respect  others  have  for
them  to  sell  potions  or  medicines  that  do  not  really  work.

Some  companies  that  make  and  sell  medicines  use  their  reputations  to  mislead,
too.  When  drug  companies  act  in  this  way,  whole  communities  can  be  put  in
danger.  For  example,  a US  drug  company  named  Eli  Lilly  used  to  make  a medicine

called  diethylstilbestrol  (DES).
DES  was  supposed  to  help
prevent  miscarriages.  In  fact,
DES  did  not  prevent
miscarriages.  It  caused  birth
defects  and  cancer.  Eli  Lilly
knew  that  the  drug  might  cause
these  problems  but  kept  selling
it  anyway.  And  even  after  the
drug  was  made  illegal  in  the
US,  it  was  still  sold  in  other
countries.

'f  o

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Chapter  2:  Treating  health  problems

Know  your  limits

Know  when  to  do  nothing

In  this  book,  we  talk  mostly  about  how  to  solve  health  problems.  This  is
important.  But  in  many  cases,  the  best  thing  to  do  for  a woman  in  labor  is
nothing!  A woman  who  is  healthy  is  likely  to  have  a healthy  and  happy  birth.

Most  births  go  well.

Doing  unnecessary  procedures  can  cause  serious  problems.  Respect  the  process
of  birth.  When  all  is  going  well,  simply  watch  and  wait.

Know  when  to  get  help

No  matter  how  skilled  you  are,  there  will  be  times  when  you  need  help.  Knowing
when  to  get  medical  advice,  when  to  enlist  the  support  of  another  midwife,  or
when  to  send  a woman  to  a doctor  or  medical  center,  is  a skill  that  every  midwife
must  try  to  master.

It  can  be  hard  to  know  when  to  get  medical  help.

Hospitals  and  medical  centers  are  often  expensive  or  far
away.  Many  women  are  afraid  to  go  to  them.  A woman  with
a small  problem  may  want  to  stay  home.  She  may  not  want
to  go  to  a medical  center  unnecessarily.  But  if  she  stays  at
home  without  help,  the  problem  could  get  much  worse.

If  you  know  a woman  is  having  a problem  like
hemorrhage,  infection,  or  pre-eclampsia,  do  not  delay  —
get  medical  help.  The  sooner  you  go,  the  better  her  chances
of  recovery.  Sometimes  you  may  have  to  rush,  sometimes
you  may  not.  If  labor  is  long,  for  example,  and  you  live  and
work  very  far  from  a medical  center,  you  must  start  your
journey  early,  before  the  problem  is  serious.  If  the  medical
center  is  only  across  the  road,  you  have  more  time.

Know  when  to  take  action  at  home

Midwives  who  work  very  far  from  medical  care  must  also  sometimes  give
treatments  that  are  better  done  in  a medical  center  or  hospital  — because  the
woman  needs  the  treatment  right  away.  For  example,  if  a woman  in  an  isolated
village  has  a seizure  from  eclampsia,  her  midwife  should  give  her  magnesium

sulfate,  a drug  that  is  not  usually
safe  to  give  at  home.  Then  the
midwife  should  take  the  woman
to  a medical  center  right  away,
because  both  the  seizure  and  the
magnesium  sulfate  are  very
dangerous.

Deciding  when  to  get
help  can  be  difficult.
When  in  doubt  —
get  medical  help.

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www.  nesperian. ore

Finding  root  causes  of  health  problems

WARNING ! In  this  book,  we  explain  how  to  do  some  procedures
that  can  be  dangerous  if  they  are  not  done  correctly,  such  as:  how
to  do  a pelvic  exam,  how  to  insert  an  IUD,  or  how  to  sew  a tear.

It  is  not  enough  to  read  about  these  procedures.  Before  you  do
many  of  the  procedures  in  this  book,  first  watch  other
experienced  health  workers  doing  them.  Then  practice  while
someone  with  experience  and  training  watches  and  helps  you.

Only  after  you  have  practiced  many  times  in  this  way  is  it  safe  for
you  to  do  these  procedures  on  your  own.

Finding  root  causes  of  health  problems

As  a midwife,  you  must  find  and  treat  the  immediate  causes  of  health  problems.  For
example,  think  again  about  the  story  of  Celeste  and  Elena.  The  immediate  cause  of
Elena  being  tired  was  her  anemia.  If  she  eats  more  iron-rich  foods  or  perhaps  takes
iron  pills,  her  anemia  will  probably  get  better.  By  looking  at  the  immediate  causes,
we  can  help  people  feel  better  or  save  their  lives,  especially  in  emergencies.

Treating  the  immediate  cause  is  very  important.  But  if  we  only  treat  the
immediate  cause,  the  problem  may  not  truly  be  solved.  It  may  come  back,  or  it  may
affect  others  in  the  community.  Sickness  usually  results  from  a combination  of
causes  — direct  causes,  like  germs  or  lack  of  iron,  and  less  direct  root  causes  that
may  be  social,  economic,  or  political.  By  finding  these  root  causes,  you  can  prevent
problems  from  happening  again.

In  the  case  of  Elena,  there  are  many  root  causes  of  her  problem.  Celeste  could
probably  figure  out  some  of  those  causes  herself.  Better  yet,  she  and  Elena  could
meet  with  a group  of  people  from  the  community  to  help  think  about  the  problem,
because  anemia  is  not  just  Elena's  problem,  it  is  a community  problem.

Why  was  Elena  tired?

But  why  did  she  have  anemia?

But  why  didn't  she  eat
enough  iron-rich  foods?

But  why  else?

But  why  couldn't  she  afford
meat?

But  why  do  farmers  make
so  little  money?

Because  she  had  anemia.

Because  she  did  not  eat  enough  foods  with  iron.
She  did  not  know  which  foods  had  iron.

She  could  not  afford  meat.

Because  she  is  poor.  She  and  her  husband
work  on  a farm  and  make  little  money.

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21

Chapter  2:  Treating  health  problems

After  you  have  asked  everyone  "why"  in  this  way  for  some  time,  you  will  find
that  there  are  many  reasons  why  Elena  had  anemia.  This  exercise  also  shows  why
anemia  is  not  just  a problem  for  Elena  but  for  most  of  the  women  in  the  village.
Indeed,  it  is  a problem  for  most  women  in  most  villages  and  poor  communities
around  the  world.

Look  deeply  to  prevent  more  problems

Finding  the  many  root  causes  of  health  problems  means
looking  hard  at  the  different  parts  of  people's  lives  that
contribute  to  the  problem.

For  example:  A fistula  is  a terrible  complication  of
some  births.  When  a labor  goes  on  much  too  long,  the
tissue  inside  a woman's  vagina  can  become  crushed  and
break  open,  leaving  a hole  to  her  bladder.  This  cai
serious  health  problems  and  constant  leaking  of
urine.  To  prevent  a fistula,  simply  prevent  a long
labor.  If  a woman  is  in  labor  for  more  than  a day,
bring  her  to  a medical  center  or  hospital.

But  by  looking  more  deeply  at  the  many
causes  of  a long  labor,  we  can  do  more  to
prevent  fistula  and  other  related  problems.

• Young  girls  who  do  not  eat  well  often  grow  up  to  have  small  bones
(including  small  pelvises).  An  abnormally  small  pelvis  can  cause  a
long  labor.  Some  young  girls  do  not  eat  enough  because  their
families  cannot  afford  food.  Some  are  not  fed  enough  because  they
are  not  considered  as  important  as  boys.

• Some  girls  have  children  too  young.  Young  girls  have  long,
complicated  labors  because  their  bodies  have  not  fully  grown.  Girls
might  marry  and  have  children  early  because  it  is  the  custom  of  their
communities  or  because  their  parents  are  poor  and  cannot  care  for
them.  Or  both.

• Women  in  bad  health  are  more  likely  to  have  long,  complicated
labors.  Anyone  can  have  health  problems,  but  those  who  do  not
have  access  to  basic  health  care  are  in  the  greatest  danger.

• Rural  and  poor  women  cannot  easily  get  medical  help  in  an
emergency.

To  prevent  fistulas,  must  we  simply  get  women  to  hospitals  faster,
or  can  we  also  work  to  change  the  conditions  that  cause  long  labors,
like  poor  nutrition  of  young  girls  and  too-early  marriage  and  childbirth?
How  can  we  work  to  stop  the  root  causes  of  these  problems  — poverty
and  unfair  treatment  of  women  and  girls?

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Finding  root  causes  of  health  problems

Make  change  in  your  community  to
prevent  health  problems

Most  deaths  and  injuries  from  pregnancy  and  childbirth  can  be  prevented  by
looking  at  and  treating  root  causes.  But  to  do  so,  a community  must  look  beyond
the  experiences  of  individual  women.  Look  at  the  common  dangers  that  affect  all
women  in  pregnancy  and  birth.  And  use  the  skills  of  every  community  member  to
protect  women's  health.

Midwives,  who  are  most  experienced  with  birth,  can  tell  others  in  the
community  why  women  are  dying  and  being  injured  during  birth.  Families,
midwives,  and  other  health  workers  and  community  members  can  work  together
to  make  changes,  small  and  large,  to  improve  health  for  all.  When  everyone  in  the
community  becomes  involved  with  health,  we  can  do  much  more  than  one
midwife  alone.

How  to  start

Lack  of  healthy  food,  dirty  drinking  water,  lack  of  transportation  in  emergencies,
and  alcohol  abuse  are  a few  of  the  problems  that  contribute  to  serious  health
problems  for  women.  These  can  all  be  addressed  when  they  are  not  considered
individual  problems  and  when  the  whole  community  works  together  for  change.
But  it  can  be  difficult  to  know  where  to  start.  A good  first  step  is  to  meet  with
community  members  to  talk.  If  you  teach  birth  classes  to  pregnant  women,  meet
with  other  midwives,  or  are  a member  of  a social  or  church  group,  you  can  use  that
group  to  solve  problems.

WWW.

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23

Chapter  2:  Treating  health  problems

First,  name  the  problems  you  are  facing.

You  have  all  read  how  to  stay
healthy  in  pregnancy.  But  not
everyone  can  do  these  things.  Why?

How  can  we
eat  well  when
there  is  no
money  for
food?

We  always  have
to  wait  hours  to
be  seen  at  the
clinic.

After  you  have  named  some  of  the  problems  in  the  community,  choose  what
to  work  on  first.  It  might  be  the  problem  that  is  the  most  common,  the  problem
that  causes  the  most  serious  harm,  or  the  problem  that  can  be  most  easily  solved.
List  every  idea  the  group  can  think  of  to  work  on  this  problem.  Then  focus  on
solutions  that  someone  in  the  group  can  make  happen.

We  agree  that  the  whole  \
community  can  help  \
pregnant  women  eat  \

better.  But  how?  J

I could  plant'
some  green
vegetables  in
the  coffee  field.

We  should  talk  to  t/re\
storekeeper.  He  should  \
sell  more  beans  and  \

rice  and  less  liquor!  J

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A Book  for  Midwives  (201  0)

1*Ahn*ly?L

www. nesperian.org

Finding  root  causes  of  health  problems

Make  a plan.  You  will  need
to  decide  who  will  do  each  task,
what  they  will  need  to  do  it,  and
when  they  will  do  it.

I can  pay  for  the  seeds ,
but  we  all  must  work
together  to  plant  and
care  for  them.

Be  sure  to  meet  again  to  talk  about  how  the  plan  is  going.

^ The  seedlings  are  coming\
up  well.  And  everyone  1
has  been  taking  turns  1
watering  them  J

I I talked  to  the  storekeeper ,
/ and  he  said  he  will  not  sell
I beans  — they  don’t  make
y^^enough  money  for  him.

goi

storekeeper  together.
If  we  tell  him  we’ll  stop
buying  anything  from
him , he  may  listen  to
our  demands!

Midwives  can  make  change

Midwives  and  the  women  they  serve  may  face  any  kind  of  health  problem,  from
simple  ones  like  nausea  to  serious  ones  like  a bad  hemorrhage.  But  when
midwives  work  carefully  to  discover  causes,  and  use  wise  judgment  and  support
from  the  community,  they  can  solve  nearly  any  problem,  even  many  of  the  most
difficult  ones.

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A Book  for  Midwives  (201  0)

25

Chapter  3

A woman's  body  in  pregnancy

In  this  chapter:

A woman's  sexual  and  reproductive  parts

How  women  become  pregnant

How  the  baby  grows 30  Menopause

Infertility 30

WWW.

nespefia.ri.org

A woman's  body
in  pregnancy

In  this  chapter,  we  describe  the  parts  of  a woman's  body  that  are  most  affected  by  sex,
pregnancy,  and  birth.  We  call  these  parts  sexual  or  reproductive  parts.  We  also  explain
how  pregnancy  happens,  and  how  a woman's  body  changes  during  pregnancy.

A woman's  sexual  and  reproductive  parts

A woman's  genitals  (vulva)

outer  lips

inner  lips

opening  of
the  vagina

oy  clitoris

a very  sensitive  spot
that  can  give  sexual
pleasure  when  touched

urethra

~ the  opening  that
urine  comes  out  of

anus

the  opening  of
the  rectum  and
intestine,  where
stool  comes  out

The  pelvis

The  bones  below  the  belly
are  called  the  pelvis.

pelvis

$ | , .

I t pubic

bone

The  pelvis  is  shaped  like  a bowl
with  a hole  in  the  bottom.

through  the  hole  to  get  out.

27

Chapter  3:  A woman's  body  in  pregnancy

The  womb,  tubes,  and  ovaries

The  womb  (uterus)  is  a hollow  muscle.  It  sits
inside  the  pelvis.  Monthly  bleeding  comes
from  the  womb,  and  the  womb  is  where  the
baby  grows  during  pregnancy.

intestines

kidney

The  womb  is
in  the  woman's
belly  along  with
her  other  organs.

bladder

If  you  could  see  the  womb  inside  a woman's  belly,  it  would  look  like  this:

womb

tube

The  tubes  connect
the  womb  to  the

cervix

The  cervix  is  the  opening
of  the  womb  into  the
vagina.  It  is  usually  closed
and  plugged  with  mucus.

ovary

The  ovaries  hold  tiny
eggs.  Some  people
call  eggs,  "the  seeds
of  the  woman."

vagina

The  vagina  is  the  opening  in
the  outside  of  the  woman's
body  that  leads  to  the  cervix
and  womb.

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A Book  for  Midwives  (201  0)

How  women  become  pregnant

How  women  become  pregnant

About  once  a month,  a woman's  Men  make  tiny  cells  called  sperm  inside

ovary  releases  a tiny  egg.  The  of  their  testicles.  When  a man  ejaculates

egg  moves  down  the  tube  and  (comes),  a fluid  called  semen  comes

into  the  womb.  out  of  his  penis.  Millions  of  sperm  cells

come  out  in  that  fluid.

The  semen  and
sperm  travel  through
this  tube  and  out  of
the  penis.

testicle

The  sperm  is  made
in  the  testicles.

If  a man  ejaculates  inside  a woman's  vagina  during  sexual  intercourse,  his
sperm  cells  can  travel  through  her  vagina,  through  her  womb,  and  into  her  tubes.

If  the  woman  and  man  have  sexual  intercourse  near  the  time  of  the  month  that
the  woman's  egg  is  moving  down  her  tube,  one  of  the  man's  sperm  cells  may  meet
her  egg.  The  egg  may  then  plant  itself  in  the  lining  of  the  womb.  If  this  happens,
the  woman  becomes  pregnant.

Every  month  that  the  woman  does  not  become  pregnant,  the  bloody  lining  of
her  womb  comes  out  about  2 weeks  after  she  releases  the  egg.  We  call  this
monthly  bleeding,  or  menstruation.

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A Book  for  Midwives  (201  0)

staying  well

Chapter  3:  A woman's  body  in  pregnancy

How  the  baby  grows

After  a sperm  and  egg  join  inside  a woman's  womb,  they  combine  to  become  one
group  of  cells  that  multiply  and  grow  into  a baby.

The  mother's  blood  contains  oxygen  from  the  air  she  breathes  and  nutrition
from  the  food  she  eats.  Her  blood  then  passes  air  and  food  to  the  baby  through  the
cord  and  placenta.

During  the  first  3 months  of  pregnancy,  it  is  hard  to  see  much  happening  from
the  outside.  But  inside  the  womb,  the  baby  is  forming  organs,  bones,  and  other
body  parts.  During  these  early  months,  it  is  especially  important  that  a pregnant
woman  avoid  noisonous

When  a person  has  difficulty  having  a child,  he  or  she
is  infertile.  For  a couple  that  wants  to  have  children,
infertility  can  bring  sadness,  anger,  or  shame.

Often  the  woman  is  blamed  when  she  does  not
become  pregnant.  Even  if  the  couple  gets  medical  help,
many  doctors  will  check  only  the  woman  for  fertility  problems.

But  often  the  man  is  the  one  who  is  infertile.  Neither  men  nor  women  should  be
blamed  for  infertility.  And  both  need  support  during  this  difficult  time.

This  is  what

you  would
see  if  you
could  look
inside  a
pregnant
woman's
womb.

The  baby  is  connected  to  the
placenta  (afterbirth)  by  a cord,

Inside  the  womb,  the  baby
floats  in  a bag  of  fluid  called

inside  of  the  mother's  womb.

amniotic  fluid  (the  bag  of  waters).

and  the  placenta  is  attached  to  the

Infertility

30

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A Book  for  Midwives  (201  0)

WWW.

How  women  become  pregnant

Infertility  has  many  causes.  Some  cannot  be  prevented.  But
many  causes  of  infertility  are  preventable.

• Sexually  transmitted  infections  can  leave  scars
inside  a man's  or  woman's  reproductive  parts
that  prevent  pregnancy.

• Illnesses  such  as  diabetes,  tuberculosis,
malaria,  and  mumps  can  cause  infertility.

• Dangerous  chemicals  from
pesticides,  cleaning  products,  or
factories  can  get  into  the  air,  water,

or  food.  These  chemicals  can  make  it  Even  washing  clothes  that  have  dangerous
difficult  for  a woman  to  get  pregnant,  chemicals  on  them  can  harm  fertility,
or  can  harm  the  growing  baby.

• Smoking,  chewing  tobacco,  drinking  a lot  of  alcohol  or  using  drugs  can  all
harm  fertility.

There  are  other  causes  of  infertility  that  are  not  preventable.  To  learn  more,  look
at  a general  health  book  like  Where  Women  Have  No  Doctor.

Menopause

When  women  grow  older,  they  stop  bleeding  each  month  (menopause).  They  also
stop  producing  eggs  and  lose  the  ability  to  become  pregnant.
This  may  happen  suddenly,  or  slowly  over  1 or  2 years.  For
most  women,  menopause  happens  when  they  are  between
45  and  55  years  old.

During  menopause,  many  women  have  some  of  these  signs:

• changes  in  monthly  bleeding  before  it  stops  completely

• suddenly  feeling  very  hot  and  sweaty  (hot  flashes)

• vagina  becomes  smaller  and  more  dry

• sudden  changes  in  feelings

Many  women  are  relieved  when  they  do  not  have  to  worry
about  pregnancy  anymore.  As  elders,  women  can  share  the
wisdom  of  their  years  of  life  experience.

Men  make  sperm  through  most  of  their  lives,  even  when
they  are  very  old.

www. nesperian.org

31

A Book  for  Midwives  (201  0)

staying  well

Chapter  4

Helping  women  stay  healthy

n this  chapter:

Eating  well

Talking  to  women  about  food 34

Eat  more  food 34

Eat  a variety  of  foods 34

Eat  these  5 important  vitamins
and  minerals  every  day 36

Ideas  about  food  affect
women's  health

Eating  well  with  little  money

33

39

41

Caring  for  the  body  for  good  health

Keep  clean 42

Care  for  the  teeth  and  mouth 43

Exercise 43

,42

Sleep,  rest,  and  relax 44

Enjoy  the  pregnancy 44

Things  to  avoid  during  pregnancy  and  breastfeeding 45

Stay  away  from  people  with  rubella  Stay  away  from  chemicals

and  other  sicknesses

45

and  fumes

47

Avoid  taking  medicines

45

Avoid  smoking,  alcohol,

and  other  drugs

46

www. nespenan.org

32

Helping  women
stay  healthy

A woman  who  eats  well  and  takes  good  care  of  her  body  is  much  more  likely  to
have  a healthy  pregnancy  and  healthy  baby.  In  fact,  the  ways  to  stay  healthy  listed
in  this  chapter  can  be  used  by  women  and  their  families  to  stay  well  throughout
their  whole  lives.

Eating  well

Eating  well  means  eating  enough  food  and  eating
a variety  of  healthy  foods.

Eating  well:

• helps  a woman  resist  illness  and  stay  healthy.

• keeps  a woman's  teeth  and  bones  strong.

• gives  a woman  strength  to  work.

• helps  the  baby  grow  well  in  the  mother's  womb.

• helps  prevent  heavy  bleeding  after  birth.

• helps  a mother  recover  her  strength  quickly
after  birth.

Eating  well  helps  a
woman  and  her  baby  stay
healthy  and  strong.

Problems  from  poor  nutrition  (not  eating  well)

Poor  nutrition  can  cause  tiredness,  weakness,  difficulty
fighting  infections,  and  other  serious  health  problems.

Poor  nutrition  during  pregnancy  is  especially
dangerous.  It  can  cause  miscarriage  or  cause  a baby  to  be
born  very  small  or  with  birth  defects.  It  also  increases  the
chances  of  a baby  or  a mother  dying  during  or  after  birth.

1 Or

www. nesperian.org

33

Chapter  4:  Helping  women  stay  healthy

Talking  to  women  about  food

Talk  to  women  about  the  food  they  eat.  The  earlier  women  start  eating  healthier
foods,  the  better  chance  they  have  to  stay  healthy,  to  have  normal  births,  and  to
have  healthy  babies.  ^

To  find  out  whether  a woman  is
eating  well,  ask  her  what  she
usually  eats,  and  how  much.  For
example:  "What  did  you  eat
yesterday?"  Be  sure  to  tell  her  what
is  healthy  about  what  she  eats.
Then  make  a suggestion  for  how
she  could  eat  better.

I eat  cassava
every  day,  and  I
usually  have
some  fish  — or
beans  cooked
with  onions  and
tomatoes,  and  I
drink  soda  pop.

That  sounds  good.
Cassava  gives  energy.

Beans  and  fish  give
strength.  If  you  drink
fruit  juice  instead  of
soda  pop,  and  you  also
eat  some  green
vegetables,  you  will
get  more  vitamins.

Even  if  a woman  knows  the  best
foods  for  health,  she  may  not  eat  them.  Many
families  cannot  afford  to  buy  enough  food  or  a
wide  variety  of  foods.  Other  women  simply  may
not  like  the  taste  of  some  foods.  To  help  a
woman  eat  better,  suggest  healthy  foods  that  she  can  and  will  choose  to  eat.

Eat  more  food

Pregnant  women  and  women  who  are  breastfeeding  need  to  eat  more  than  usual.
The  extra  food  gives  them  enough  energy  and  strength,  and  helps  their  babies  grow.

Some  pregnant  women  feel  nauseated  and  do  not  want  to  eat.  But  pregnant
women  need  to  eat  enough  — even  when  they  do  not  feel  well.  Simple  foods  like
chapatis,  tortillas,  or  rice  can  be  easier  for  these  women  to  eat.

Eat  a variety  of  foods

It  is  important  for  pregnant
women  (like  everyone  else)
to  eat  different  kinds  of
food:  main  foods
(carbohydrates),
grow  foods  (proteins),
glow  foods  (vitamins
and  minerals),  and
go  foods  (fats,  oils,
and  sugar),  along  with
plenty  of  fluids.

For  a healthier  body,
eat  many  kinds  of  foods.

34

A Book  for  Midwives  (201  0)

www.  Hesperian. ore

Eating  well

Main  foods  (carbohydrates)

In  most  parts  of  the  world,  people  eat  one  main  food  at  each  meal.  This  main  food
may  be  rice,  maize,  wheat,  millet,  cassava,  taro,  plantain,  breadfruit,  or  another
low-cost  starchy  food.  These  foods  give  the  body  energy.  But  to  grow  and  stay
healthy,  the  body  needs  other  types  of  food  too.

Grow  foods  (proteins)

Grow  foods  contain  protein,  which  is  needed  for  the  growth  of  muscles,  bones,
and  strong  blood.  Everyone  needs  protein  to  be  healthy  and  to  grow.

Some  grow  foods  high  in  proteins:

• meat,  fish,  and  insects

Note:  Meat,  fish,  and  cheese  are  nutritious  foods  but  they  can  carry
parasites  or  disease  when  they  are  eaten  raw.  Pregnant  women  should
only  eat  fish,  meat,  or  cheese  that  is  well  cooked  or  pasteurized.

Fish,  especially  fatty  fish,  can  also  contain  mercury  and  other  poisons
because  water  is  often  contaminated.  Pregnant  women
should  avoid  fatty  fish,  to  be  safe.

Fruits  and  vegetables  are  high  in  vitamins  and  minerals.  It  is
important  for  women  to  eat  as  many  different  fruits  and  vegetables  as  they  can.

Go  foods  (sugars  and  fats)

Go  foods  contain  sugars  and  fats,  which  give  the  body  energy.  Everyone  needs
these  foods  to  be  healthy.

These  days,  many  people  eat  more  sugars  and  fats  than  they  need.  That  is
because  more  people  drink  sugary  soda  pop,  or  eat  foods  that  come  from  packages
instead  of  foods  made  at  home.  These  packaged,  sugary  foods  are  expensive  and
not  as  healthy.  They  also  damage  the  teeth.  It  is  better  to  eat  go  foods  that  are
natural,  not  packaged.

and  lentils)

• nuts  and  seeds

• legumes  (beans,  peas,

• eggs

• cheese,  milk,

and  yogurt

Glow  foods  (vitamins  and  minerals)

Glow  foods  contain  vitamins  and  minerals,  which  help
the  body  fight  infection  and  keep  the  eyes,  skin,  and
bones  healthy  and  strong.

Some  healthy  go  foods
high  in  sugars:

• fruit

• honey

• molasses

Some  go  foods
high  in  fats:

nuts  and  seeds
avocados

vegetable  oil,
butter,  ghee,  and  lard

fatty  meat

WWW.

Tian.org

35

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Chapter  4:  Helping  women  stay  healthy

Eat  these  5 important  vitamins  and  minerals  every  day

Pregnant  and  breastfeeding  women  need  more  of  five  vitamins  and  minerals  —
iron,  folic  acid,  calcium,  iodine,  and  vitamin  A — than  other  people  do.  Pregnant
women  should  try  to  get  these  vitamins  and  minerals  every  day  because  the  baby
needs  them  to  grow  and  be  healthy.  Every  pregnant  woman  needs  enough  for  the
baby  and  for  herself.

Iron

Iron  helps  make  blood  healthy  and  prevents  anemia  (weak  blood,  see  page  116).

A pregnant  woman  needs  a lot  of  iron  to  have  enough  energy,  to  prevent  too
much  bleeding  at  the  birth,  and  to  make  sure  that  the  growing  baby  can  form
healthy  blood  and  store  iron  for  the  first  few  months  after  birth.

These  foods  contain  a lot  of  iron:

• beans,  peas,  and  lentils

• sunflower,  pumpkin,  and  squash  seeds

• dark  green  leafy  vegetables

• breadfruit

• yams

• hard  squash
molasses

meat  (especially  liver,  kidney,  and
other  organ  meats)

poultry  (birds)

grasshoppers,  crickets,  and  termites
fish,  clams,  and  oysters

Other  ways  to  get  more  iron:

• Eat  iron  foods  with  citrus  fruits  or  tomatoes.  The  vitamin  C in  these  foods
helps  a woman  absorb  iron  into  her  system.

• Cook  food  in  iron  pots  or  add  a clean  piece  of  iron  — like  an  iron  nail  —
to  the  cooking  pot.  Only  use  a nail  that  you  know  is  made  of  pure  iron,
not  a mix  of  metals.

• Put  a clean  piece  of  pure  iron,  like  an  iron  nail,  in  a
little  lemon  juice  for  a few  hours.  Drink  the  juice
mixed  with  clean  water.

It  can  be  difficult  for  a pregnant  woman  to  get  enough
iron,  even  if  she  eats  iron-rich  foods  every  day.  If  possible,
she  should  also  take  iron  pills  or  iron  syrup.  These
medicines  may  be  called  ferrous  sulfate,  ferrous  gluconate,
ferrous  fumerate,  or  other  names.

In  many  places  health  centers  will  give  iron  pills  to
pregnant  women.  Sometimes  iron  pills  are  combined  with  folic  acid.  The  iron  pills
may  make  it  hard  for  the  woman  to  pass  stool  (constipation),  and  her  stool  may
turn  black.  These  problems  should  get  better  in  a few  days.  (See  page  76.)

WWW

.nespenan.org

36

A Book  for  Midwives  (201  0)

Eating  well

Hookworm  and  malaria  can  cause  anemia

Women  with  hookworm  are  likely  to  have  anemia.  Hookworm  can
easily  be  treated  with  mebendazole  or  albendazole,  though  these  drugs
should  not  be  taken  in  the  first  3 months  of  pregnancy.  These  drugs
have  not  been  tested  enough  to  be  sure  that  they  are  safe  for  women  who
are  in  the  later  months  of  pregnancy  or  who  are  breastfeeding.  However,
most  doctors  believe  that  the  benefit  of  treating  hookworm  is  greater
than  the  possible  harm  of  these  medicines.

If  hookworm  is  common  in  your  community,  ask  your  local  health
authority  what  treatment  is  recommended  for  pregnant  women.

Malaria  can  also  cause  anemia  and  other  serious  problems  in
pregnancy.  See  page  98  for  how  to  prevent  or  treat  malaria.

Folic  acid  (folate)

Lack  of  folic  acid  can  cause  anemia  in  the  mother  and  severe  birth  defects  in  the
baby.  To  prevent  these  problems,  it  is  most  important  for  a woman  to  get  enough
folic  acid  before  she  gets  pregnant  and  in  the  first  few  months  of  pregnancy.

These  foods  contain  a lot  of  folic  acid:

dark  green  leafy  vegetables

meat  (especially  liver,  kidney,
and  other  organ  meats)

peas  and  beans

sunflower,  pumpkin,  and
squash  seeds

whole  grains  (brown  rice,
whole  wheat)

fish
eggs

mushrooms

Some  women  also  take  folic  acid  pills.

Folic  acid  pills

• take  0.5  to  0.8  mg  (500  to  800  meg)  folic  acid

by  mouth,  1 time  each  day

www. JlCSpCri3Tl.org

Calcium

A growing  baby  needs  a lot  of  calcium  to
make  new  bones,  especially  in  the  last  few
months  of  pregnancy.  Women  need
calcium  for  strong  bones  and  teeth.

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Chapter  4:  Helping  women  stay  healthy

These  foods  contain  a lot  of  calcium:

• milk,  curd,  yogurt,  and  cheese

• ground  sesame  (tahini)

• almonds

• green  leafy  vegetables

• yellow  vegetables  (hard  squash,  yams)

• shellfish

• lime  (carbon  ash)

• bone  meal  and  eggshells

Women  can  also  get  more  calcium  in  these  ways:

• Soak  bones  or  eggshells  in  vinegar  or  lemon  juice  for  a few
hours.  Then  use  the  liquid  to  make  soup  or  eat  with  other  foods.

• Add  lemon  juice,  vinegar,  or  tomatoes  when  cooking  bones.

• Grind  eggshells  into  a fine  powder  and  mix  into  food.

• Soak  maize  in  lime  (carbon  ash)  before  cooking  it.

Iodine

Iodine  prevents  goiter  (swelling  of  the  throat)  and  other  problems  in  adults.  Lack
of  iodine  in  a pregnant  woman  can  cause  her  child  to  have  hypothyroidism
(cretinism),  a disability  that  affects  thinking  and  brain  development.

The  easiest  way  to  get  enough  iodine  is  to  use
iodized  salt  instead  of  regular  salt.

These  foods  contain  a lot  of  iodine:

• shellfish  (like  shrimp)

• fish

• seaweed

• egg  yolks

• liver

If  hypothyroidism  or  goiter  are  common  in  your
area,  find  out  if  the  local  health  ministry  will  give
iodized  oil  by  mouth  or  iodine  by  injection.  If  not,
women  can  make  iodine  solution  at  home  with  polyvidone  iodine.

To  make  an  iodine  solution  to  drink

Add  1 drop  of  Lugol's  iodine  to  1 glass  of  clean  drinking  water  or  milk.

p In  places  where  goiter  or  cretinism  are  common,  everyone  except
breastfeeding  babies  should  drink  1 glass  of  this  iodine  solution

0 every  month  of  his  or  her  life.  This  is  especially  important  for  children

and  pregnant  women.  Do  not  take  more  iodine  than  this.  Too  much
. ■

is  dangerous.

Store  iodine  at  room  temperature,  and  in  dark  containers  to  protect
it  from  light.

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www.  Hesperian,  or

Eating  well

Vitamin  A

Vitamin  A prevents  night  blindness  and  helps  fight
infections.  Lack  of  vitamin  A also  causes  blindness  in
children.  A woman  needs  to  eat  plenty  of  vitamin  A
during  pregnancy  and  while  breastfeeding.

Dark  yellow  and  green  leafy  vegetables  and  yellow  fruits  have  vitamin  A.

Along  with  eating  healthy  foods,  women  should  drink  plenty
of  clean  water  and  other  fluids  every  day.  Fruit  juices,  coconut
water,  animal  milks,  and  many  herbal  teas  are  all  healthy  fluids
to  drink.

Ideas  about  food  affect  women's  health

Some  beliefs  about  foods  are  harmful  — especially  when  people  believe  that
women  should  not  eat  as  much  as  men  do,  or  should  not  eat  a variety  of  foods.

It  is  not  safe  for  girls  to  be  fed  less  than  boys

Girls  need  as  much  food  as  boys  — to  grow  and  learn  and  work.  If  a girl  does  not
get  enough  food,  her  bones  may  not  grow  well.  This  can  cause  serious  problems
during  labor  when  the  girl  becomes  a woman  and  has  babies  of  her  own.

When  a woman  must  feed  her  family  first,
she  may  not  get  enough  to  eat

A woman  may  be  taught  to  feed  her  family  before
herself.  She  eats  only  what  is  left  and  often  does
not  get  as  much  as  others  in  the  family.  This  is
never  healthy.  And  when  a woman  is  pregnant,
or  has  just  had  a baby,  it  can  be  very  dangerous.

If  the  family  will  not  help  the  woman  eat
enough,  she  may  need  to  hide  food,  eat  while
she  is  cooking,  or  eat  while  her  husband  is
out  of  the  house.

Packaged  and  processed  foods  are  rarely  as  good  as  homemade

People  are  eating  more  and  more  packaged  and  processed  foods.  Some  people  like
the  taste,  and  some  people  think  that  packaged  foods  are  healthier.

Packaged  foods  may  be  advertised  as  the  healthiest  choice,  but  this  is  rarely  the
truth!  Advertisers  will  say  anything  just  to  sell  products.  Some  packaged  foods  are
fortified  with  vitamins  and  minerals,  but  our  bodies  cannot  use  these  added-on
vitamins  as  well  as  our  bodies  use  the  vitamins  that  we  get  from  eating  whole,
fresh  foods.  Most  packaged  foods  contain  more  sugar,  salt,  and  fat  than  we  need.

Many  are  full  of  chemicals  to  keep  the  food  looking  and  tasting  fresh,  and  some  of
these  chemicals  have  not  been  carefully  tested  to  be  sure  of  their  safety.

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Chapter  4:  Helping  women  stay  healthy

Avoiding  foods  can  be  dangerous

In  many  places,  pregnant  women  are  told  not  to  eat  certain  foods.  In  these
communities,  people  believe  that  these  foods  will  harm  the  baby.  At  the  same
time,  a doctor  or  a midwife  may  tell  a woman  it  is  important  to  eat  those  same
foods.  This  can  be  confusing  for  the  woman.

Avoiding  foods  can  be
dangerous.  For  a woman  to
be  healthy  during  and  after
pregnancy,  she  must  eat  a
wide  variety  of  foods  — main
foods,  grow  foods,  glow
foods,  and  go  foods.  Eating
only  one  kind  of  food  is  not
enough.

If  a woman  does  choose  to
avoid  certain  foods,  make  sure
she  is  getting  enough  of  each
kind  of  food,  and  enough
vitamins  and  minerals  from  her  food.

Everyone  needs  to  eat  a wide  variety  of  foods.

Finding  creative  answers

Beliefs  about  food  can  be  hard  to  change.  But  you  may  find  ways  to  help
women  eat  better  without  working  against  their  beliefs.  This  example  is
based  on  a true  story:

Maria  is  a midwife  in  Guatemala.  She  and  her
people  believe  that  some  foods  are  "hot"  foods,  and
some  foods  are  "cold"  foods.  They  believe  that
pregnant  women  should  not  eat  cold  foods.

To  Maria  and  her  people,  beans  and  eggs  are  cold
foods  (even  when  they  are  cooked).  But  Maria  knows
that  beans  and  eggs  are  good,  low-cost  ways  for
pregnant  women  to  get  the  protein  and  iron  they  need.

Maria  wants  pregnant  women  to  eat  well,  but  they
will  not  eat  cold  foods.  And  Maria  too  thinks  that  cold
foods  may  not  be  good  for  pregnant  women  to  eat.  Her  solution  is  simple
and  smart.  She  tells  pregnant  women  to  eat  beans  and  eggs  with  a little  hot
pepper  or  another  hot  food.  This  way,  the  foods  will  not  be  cold  anymore.

Maria  has  found  a creative  answer  to  a problem.  She  has  found  a way  for
pregnant  women  to  eat  better  and  has  shown  respect  for  the  beliefs  of  her
community.

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Eating  well

Eating  well  with  little  money

The  biggest  cause  of  poor  nutrition
is  poverty.  Rich  people  in  wealthy
countries  can  buy  any  foods  they
want,  while  those  in  poor
communities  cannot.  And
within  each  community,  some
can  afford  to  eat  better  than
others.  A few  people  own  most
of  the  land  or  businesses,  and
make  money  off  of  the  work  of
others.  Even  within  each
family,  a father  may  eat  better
than  his  wife  or  children.

To  learn  more  about  the
root  causes  of  poverty  and
ways  to  work  for  change,
see  the  books  Where  There  Is
No  Doctor  and  Helping
Health  Workers  Learn.

The  problems  of  hunger  and  poor  nutrition  will  not  be
solved  until  we  all  share  with  each  other  fairly.

Even  a very  poor  family  can  eat  better  by
spending  money  wisely.  A father  who  buys  alcohol
and  tobacco  could  instead  buy  nutritious  food  or
he  could  buy  a hen  to  lay  eggs.  A mother  who  buys
her  children  sweets  or  soda  pop  could  instead  buy
eggs,  beans,  or  other  low-cost  healthful  foods.

Here  are  some  ideas  that  families  can  use  to  eat
better  with  little  money:

Breast  milk

Breast  milk  costs  nothing,  and  has  all  the  nutrition  a baby  needs.  Young  children
do  not  need  fortified  milks  — especially  if  they  are  still  breastfeeding  and  eating
other  foods.

Beans , peas , and  lentils

Beans  and  other  legumes  have  a lot  of
protein  and  vitamins,  and  they  usually
do  not  cost  much.  They  have  even
more  vitamins  if  they  are  sprouted
before  being  eaten.

Grow  beans  this  year.  Next  year,  maize.

Planting  legumes  makes  soil  richer.

Other  crops  will  grow  better  in  a field  where  legumes  once  grew.

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41

Chapter  4:  Helping  women  stay  healthy

Less  expensive  meats  and  animal  products  A.

Blood  and  organ  meats  like  liver,  heart,  and  kidney  have  a
lot  of  iron  and  may  cost  less  than  other  meats.  Fish  and

chicken  are  as  healthy  as  other  meats,  and  usually  cost  less  — JjL  _

especially  for  a family  that  fishes  or  raises  their  own  chickens.  ^ C 5o

Eggs  have  a lot  of  protein,  iron,  and  vitamin  A.  Eggs  give  more  protein  for  less
money  than  almost  any  other  food.

Whole  grains

Grains,  like  wheat,  rice,  and  corn,  are  more  nutritious  when  they  have  not  been
refined  (processed  to  take  out  the  color).  Taking  out  the  color  takes  out  healthy
things  too.  White  bread  and  white  rice  have  less  vitamins,  minerals,  and  proteins
than  brown  bread  or  brown  rice.

Vegetables  and  fruits

When  vegetables  are  boiled  or  steamed,  some
of  the  vitamins  from  the  foods  go  into  the
cooking  water.  Use  this  water  to  make  soups.

Use  only  a little  water
to  cook  vegetables.

The  outside  leaves  of  plants  are  usually  thrown  away,
but  sometimes  they  can  be  eaten.  The  leaves  of  the  cassava
plant  have  more  vitamins  and  protein  than  the  root.

Many  wild  fruits  and  berries  are  rich  in  vitamins  and
natural  sugars  that  give  energy.

Avoid  buying  vitamins

Most  of  the  time  people  can  get  enough  vitamins  and  minerals  by  eating  a variety
of  foods.  Buying  vitamins  is  usually  a waste  of  money.

But  pregnancy  and  breastfeeding  are  times  that  women  may  need  to  take  extra
vitamins  — more  than  what  they  can  get  from  food.  Vitamin  pills  work  as  well  as
vitamin  injections,  and  cost  less.

Caring  for  the  body  for  good  health

For  a woman  to  stay  healthy  in  pregnancy  — or  anytime  — it  is  wise  for  her  to
keep  clean,  exercise,  and  get  plenty  of  rest.

Keep  clean

Keeping  the  body  clean  helps  prevent  infections.  If  possible,  the  mother  should
regularly  wash  her  body,  including  her  genitals,  with  clean  water.

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1*Ahn*ly?L

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Caring  for  the  body  for  good  health

Care  for  the  teeth  and  mouth

Healthy  teeth  help  a person's  whole  body  be  healthy,  and  care  for  the  teeth
is  especially  important  in  pregnancy  because  unhealthy  teeth  can  lead  to
gum  infections.  This  can  cause  a baby  to  be  born  too  early.

In  some  places  there  is  a saying,  "Have  a baby,  lose  a tooth."  But  this  does  not
have  to  be  true!  A woman  can  protect  her  teeth  in  these  ways:

• Eat  calcium-rich  foods.

• Avoid  sweets,  candy,  and  soda  pop.

• Clean  the  teeth  after  every  meal  with  a soft  brush,
tooth  stick,  or  rough  cloth.  Toothpaste,  salt,

or  plain  water  on  the  brush  are  helpful  but
not  necessary.

To  make  a tooth-cleaning  stick:

Clean  the  surfaces  of  all  the
teeth,  between  the  teeth,
and  the  gums  every  day.

Sharpen  this  end  to  clean  Chew  on  this  end  and  Or  tie  a piece  of  rough  cloth

between  the  teeth.  use  the  fibers  as  a brush.  on  the  end  of  a stick.

If  possible,  everyone  should  see  a dentist  or  dental  worker  regularly.

Exercise

Exercise  makes  a woman's  body
stronger.  During  pregnancy,  exercise
helps  her  body  get  ready  for  labor
and  birth.  Exercise  can  also  help  a
woman  have  energy  and  feel  happy.

Many  women  get  all  the  exercise
they  need  by  hauling  water,  working
in  the  fields,  milling  grain,  chasing
after  children,  and  walking  up  and
down  hills.

Women  who  work  sitting  or
standing  (in  offices,  stores,  or
factories,  for  example)  or  who  do  not
move  around  much  during  the  day
usually  need  more  exercise.  They  can
take  long  walks,  dance,  do  physical
work,  or  find  another  way  to  move.

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Chapter  4:  Helping  women  stay  healthy

Squeezing  exercise  (Kegels)

The  squeezing  exercise  strengthens
muscles  in  the  pelvis  and  vagina.

Doing  the  squeezing  exercise  can  help
to:

• prevent  leaking  urine.

• prevent  the  vagina  from  tearing
during  birth.

• speed  healing  after  birth.

• increase  sexual  pleasure.

A woman  can  learn  this  exercise
while  she  is  urinating.  As  the  urine
comes  out,  she  should  squeeze  the  muscles  in  her  vagina  until  the  urine  stops.
Once  she  learns  how  to  squeeze  these  muscles,  she  should  only  do  it  when  she  is
not  urinating.

The  squeezing  exercise  is  helpful  at  all  times,  not  just  during  pregnancy.

If  possible,  women  should  practice  at  least  4 times  a day,  doing  at  least
10  squeezes  each  time.

Sleep,  rest,  and  relax

Sleep  and  rest  help  women  stay  strong  and  resist  sickness.  Getting  enough  rest  also
helps  prevent  high  blood  pressure,  sick  babies,  and  other  problems.

Many  women  must  work  all  day  in  fields,  factories,
or  stores.  Then  they  must  also  haul  water,  find  fuel,
mill  grain,  cook,  clean,  and  care  for  their  families.

This  can  be  very  hard  at  any  time.  It  can  be  especially
hard  for  pregnant  women  who  need  more  rest  than
usual.

Explain  to  pregnant  women  that  it  is  important  for
them  to  rest  for  a few  minutes  every  1 or  2 hours.

Help  the  woman's  family  understand  why  it  is
important  for  her  to  rest  and  sleep.

Enjoy  the  pregnancy

If  women  have  enough  food,  rest,  and  care,  pregnancy
can  be  a wonderful  time.

Many  communities  have  rituals  and  practices  that  honor
pregnant  woman.  People  help  her  with  her  work,  bring  her
special  foods,  or  give  her  massages  or  gifts.  Customs  like
these  help  a woman  get  the  food  and  rest  she  needs,  and
help  her  feel  good  about  herself  and  her  pregnancy.

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Things  to  avoid  during  pregnancy  and  breastfeeding

Things  to  avoid  during  pregnancy
and  breastfeeding

Sicknesses,  drugs,  and  poisonous  chemicals  are  not  healthy  for  anyone.  They  are
particularly  dangerous  in  pregnancy  and  while  breastfeeding.  The  following  things
are  the  most  dangerous  in  the  first  3 months  of  pregnancy,  but  they  can  be
dangerous  at  all  times.

Stay  away  from  people  with  rubella  and  other  sicknesses

Pregnant  women
should  stay  away
from  people  with
sicknesses  or  rashes.

It  is  best  for  pregnant  women  to  stay  away  from  people  who
are  sick.  This  will  help  protect  them  from  becoming  sick
themselves.

Some  sicknesses  are  particularly  dangerous  to  pregnant
women  or  their  babies.  Rubella  (German  measles)  is  one
sickness  that  can  cause  serious  birth  defects  or  disabilities  in
the  baby,  including  deafness  and  heart  problems,  and  can
even  cause  death.

Avoid  taking  medicines

When  a woman  takes  medicines,  they  pass  through  her
blood  to  her  baby.  Medicines  that  are  safe  for  a grown
woman  or  even  a child  can  be  dangerous  to  the  tiny
baby  inside  the  womb.

Cough  syrups,  pain  relievers,  some  modern
medicines,  and  some  plant  medicines  can  all  be
dangerous.  Some  of  them  can  cause  birth  defects  or
disabilities  in  the  baby,  including  disabilities  that
affect  thinking  or  the  brain.

If  possible,  pregnant  women  and  women  who  are
breastfeeding  should  not  take  medicines.  If  a woman  is
sick  and  needs  medicine,  find  out  if  this  medicine  is
safe  in  pregnancy  or  while  breastfeeding.  Look  in  the  green  medicine  pages  at  the
end  of  this  book  (see  page  463)  or  ask  a doctor  if  the  medicine  is  safe.  If  plant
medicines  are  used  in  your  community,  try  to  learn  which  ones  are  safe  during
pregnancy  and  breastfeeding.

Most  of  the  medicines  we  recommend  in  this  book  are  safe  to  take  during
pregnancy  or  breastfeeding.  (If  they  are  not  safe,  we  will  include  a warning  about
when  they  can  be  dangerous.)  But  even  drugs  that  are  safe  should  only  be  taken
when  they  are  truly  needed.  Rest,  water,  and  healthful  foods  are  often  enough  to
cure  sicknesses  and  other  problems.

Pregnant  women  should
only  take  medicines  that
are  safe  in  pregnancy  and
that  are  truly  needed.

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Chapter  4:  Helping  women  stay  healthy

Avoid  smoking,  alcohol,  and  other  drugs

Cigarette  smoke,  alcohol,  and  other  drugs  are  all  harmful  to
the  mother.  When  a woman  smokes,  drinks,  or  takes  drugs,
they  also  pass  through  her  blood  to  her  baby.

Smoking  is  dangerous  for  anyone.  It  can  lead  to  serious
problems  including  cancer.  When  a pregnant  woman
smokes,  or  even  when  she  breathes  the  smoke  from  someone
near  her,  her  blood  vessels  get  smaller  and  do  not  carry  as
much  air  or  food  to  her  baby.  Because  of  this,  babies  of
women  who  smoke  are  more  likely  to  be  small  or  sick.

Drinking  a lot  of  alcohol  can  be  dangerous  for  anyone.

Heavy  drinking  can  lead  to  many  illnesses  including  serious
problems  of  the  liver.  When  a pregnant  woman  drinks,  even
just  1 or  2 drinks  a day,  her  baby  can  have  birth  defects  or
disabilities  that  affect  the  brain.

Some  drugs,  particularly  opium,  heroin,  cocaine,  and
barbiturates,  are  very  addictive  and  dangerous.  When  a
pregnant  woman  takes  these  drugs,  her  baby  can  be  born
with  a drug  addiction  or  with  other  serious  health  problems.

If  you  work  with  a woman  who  may  be  addicted  to
alcohol  or  other  drugs,  try  to  find  help  for  her.  She  may  be
able  to  stop  if  she  understands  the  risks  to  her  and  her  baby.

Advise  her  to  stay  away  from  people  who  are  smoking,  drinking,  or  taking  drugs.

You  may  be  able  to  help  her  find  others  in  your  community  who  have
stopped  using  alcohol  or  drugs  and  who  meet  to  support  each  other.  The  book
Where  Women  Have  No  Doctor  has  more  ideas  about  how  to  help  someone  stop
abusing  alcohol  and  drugs.

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A Book  for  Midwives  (201  0)

Whatever  a mother
puts  into  her  body
passes  to  her  baby.

Things  to  avoid  during  pregnancy  and  breastfeeding

Stay  away  from  chemicals  and  fumes

Strong  chemicals  used  for  cleaning,  and  poisons  used  to  kill  pests  in  the  fields  or
at  home,  are  dangerous  for  everyone.  They  are  especially  dangerous  to  women
who  are  pregnant  or  breastfeeding.  These  chemicals  can  cause  miscarriage,
infertility,  birth  defects,  cancer,  and  other
illnesses.

Any  chemical  with  a strong  smell  is
probably  not  safe.  Many  dangerous
chemicals  have  no  smell  at  all.

If  possible,  everyone  should  avoid
these  dangerous  chemicals.  But  a
pregnant  woman  should  have  no  contact
with  them.  She  should  not  use  them
herself  or  breathe  chemical  fumes  or  dust.

Her  family  should  not  store  food  in
containers  that  once  had  chemicals  inside.

Tiny  amounts  of  the  chemicals  may  be  left
in  the  container  even  after  it  is  washed  —
enough  to  harm  a person's  health!

Families  should  try  not  to  use
chemicals  at  all.  But  many  people  who
work  with  chemicals  have  no  choice.  It  is
part  of  their  job  at  a factory,  on  a farm,
cleaning,  or  somewhere  else.  People  who  use  chemicals  at  work  may  be  able  to
talk  to  the  other  workers  about  the  problem.  Maybe  all  the  workers  together  can
talk  to  the  owner  about  using  fewer  chemicals  or  using  safer  ones.

Poisonous  chemicals  include:

• pesticides  (chemicals  that
kill  bugs  or  weeds)  used  in
farming.

• pesticides  used  at  home  to
kill  bugs  or  rodents.

• strong  cleaners  and  solvents.

• some  kinds  of  glue  and  paint.

• gasoline,  oil,  and  other  fuels.

If  someone  in  the  family  must  work  with  chemicals,  he  or  she  should:

• use  as  few  chemicals,  and  as  little  of  each  one,  as  possible.

• keep  chemicals  away  from  places  where  food  is  stored.

• keep  chemicals  away  from  children.

• avoid  breathing  chemicals.  Wear  a mask  or  at  least  cover  the  mouth
and  nose,  and  try  to  work  where  there  is  a good  air  flow.

• avoid  getting  chemicals  on  the  skin.  Wear  gloves,  long  sleeves,  and
closed  shoes.

• after  working  with  chemicals,  change  clothes  before  coming  in
the  house.  Pregnant  women  should  not  wash  these  clothes.

1 l ft  li  t

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Chapter  5

Preventing  infection

In  this  chapter:

Preventing  infection  saves  lives 49

Infection  is  caused  by  germs 49  How  germs  get  into  the  body 50

Prevent  infection  by  keeping  germs  away 52

Clean  your  hands  and  wear  protective  clothing 53

Wash  your  hands  often 53  Protect  yourself  from  infection 56

Wear  gloves 54

Clean  the  space  and  bedding 57

Clean  the  space 57  Clean  or  sterilize  the  bedding 58

Clean  and  sterilize  tools

Soak  your  tools 59

Clean  your  tools 59

Sterilize  your  tools 59

Baking 61

Pressure  steaming 61

Get  rid  of  wastes  safely

Burying  wastes 68

59

Boiling 62

Steaming 62

Using  chemicals 63

Some  equipment  needs  special  care  . . 65

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48

Preventing

infection

Preventing  infection  saves  lives

Infection  makes  people  sick  and  can  even  kill  them.  It  is  one  of  the  most  common
causes  of  death  after  childbirth.  Procedures  that  involve  putting  medical  tools
inside  a woman's  womb,  like  inserting  an  intrauterine  device  (IUD)  or  doing
manual  vacuum  aspiration  (MVA),  can  also  cause  infection.  Much  of  the  work  of  a
midwife,  and  any  procedure  inside  the  womb  (invasive  procedure),  can  only  be
safe  if  you  are  able  to  follow  the  steps  we  outline  in  this  chapter  to  prevent
infection.

This  chapter  explains  how  to  avoid  infection  by  killing  or
controlling  harmful  germs.  Germs  are  organisms  that  carry
sickness.  Germs  are  everywhere,  but
they  are  so  small  that  they  can  only  be
seen  with  a microscope.  The  dangerous
germs  in  blood,  stool,  body  fluids
(like  semen  and  amniotic  waters),  and  dirt
can  cause  serious  sickness  when  they  get  Germs  live  in

into  someone's  body.  body  fluids,

like  blood.

Infection  is  caused  by  germs

Some  sicknesses,  like  arthritis,  diabetes,  asthma,  and  epilepsy,  are  not  caused  by
germs.  They  cannot  be  passed  from  one  person  to  another.

Other  sicknesses,  like  measles,  hepatitis,  tetanus,  womb  infection,  HIV,  and  the
flu,  are  called  infections  and  are  caused  by  germs.  People  get  sick  when  the  germs
that  cause  these  infections  get  inside  their  bodies.

Germs  can  live  on
tools,  even  tools
that  look  clean.

www. nesperian.org

Chapter  5:  Preventing  infection

How  germs  get  into  the  body

Germs  can  get  inside  the  body  in  different  ways.

Some  germs  pass  through  semen  or  vaginal  mucus

(body  fluids)  when  people  have  sex.  HIV  and  other
sexually  transmitted  infections  like  chlamydia  and
gonorrhea  can  spread  this  way.

Some  germs  pass  through  blood  when  the  blood  or  body
fluid  of  an  infected  person  get  into  a cut  or  through  the
skin  — like  with  a needle  that  has  been  used  for  piercing
or  injections.  HIV,  hepatitis  B,  and  hepatitis  C can  spread
this  way.

Some  germs  live  in  dirty  water  and  pass  when  people
drink  it.  Cholera  and  diarrheal  diseases  spread  this  way.

Some  germs  live  in  dirt,  on  skin,  or  in  the  air,  and  are  not

dangerous  unless  they  get  into  a person's  blood.  These  germs
can  get  into  the  blood  when  an  instrument  that  has  germs
on  it  is  used  inside  a woman's  womb,  or  to  cut  the  skin  or  a
baby's  cord.  Tetanus  and  womb  infection  can  spread  this  way.

Some  germs  pass  through  the  air  when  a sick  person
coughs  or  sneezes.  Colds,  flu,  and  tuberculosis  can
spread  this  way.

Keep  sick  people  away  from  births

One  simple  thing  midwives  can  do  to  prevent
infection  is  to  keep  sick  people  away  from  women
who  are  pregnant  or  giving  birth.  Keep
anyone  who  has  a sore  throat,  cough,  fever,  or
other  illness  that  passes  through  germs  away
from  births.  And  do  not  let  anyone  with  a sore
on  his  or  her  hands  or  face  touch  a new  baby.

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www.  Hesperian. ore

Preventing  infection  saves  lives

If  you  are  sick  but  you  must  go
to  a birth,  you  can  cover  your  mouth
and  nose  with  a scarf,  a folded  cloth
or  a mask.  Wash  your  hands  often
and  cover  your  mouth  when  you
sneeze  or  cough.  Be  sure  to  wash
your  hands  after  each  time  you
sneeze  or  cough.  Try  not  to  touch
the  new  baby  too  much.

Anyone  may  carry  germs  that  cause  sickness

People  do  not  always  know  that  they  have  an  infection.  And  there  is  no  way  to  tell
for  sure  what  germs  a person  has  just  by  looking  at  her.  Some  people  have  germs
in  their  blood  or  other  body  fluids  but  do  not  seem  sick.

To  be  safe,  and  to  stop  the  spread  of  dangerous
infections  like  hepatitis  and  HIV,  health  workers
must  treat  everyone  as  if  they  might  have  dangerous
germs  in  their  body  fluids.  Health  workers  can
prevent  germs  from  spreading:

• by  wearing  gloves  and
other  protective  clothing,
to  prevent  blood  and
other  body  fluids  that
contain  germs  from
getting  on  themselves  or
others.

• by  cleaning  and  sterilizing  the
tools  they  use  during  births  and
other  procedures.

Note:  Good  general  health  can  help  avoid  infection.  Healthy  eating,
enough  rest,  and  emotional  and  spiritual  well-being  are  all  important
for  staying  healthy.  Sometimes  they  are  enough  to  help  people  fight
germs  that  get  inside  the  body  so  the  person  does  not  get  sick.

But  during  birth  and  invasive  medical  procedures,  a woman's  body  is
more  open  and  vulnerable  to  infection,  and  good  general  health  is
usually  not  enough.  Germs  that  are  usually  kept  out  of  the  body  can
get  into  the  womb.  Any  cut  in  the  skin  also  makes  a person  more
vulnerable  to  infection  because  the  skin  usually  helps  keep  germs  out
of  the  body.  Even  an  injection  can  cause  an  infection  if  the  syringe  has
harmful  germs  on  it.

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infection

Chapter  5:  Preventing  infection

Prevent  infection  by  keeping  germs  away

Here  are  the  basic  rules  to  prevent  infection.

Clean  your  hands  and  wear  protective  clothing.

Wash  your  hands  often  and  wear  protective  clothing  to
prevent  spreading  germs  from  one  person  to  another  and
to  keep  germs  away  from  yourself  (see  page  53).

Clean  the  space  and  bedding.

Clean  the  area  where  births  and  exams  happen,  to
keep  germs  away  (see  page  57).

Clean  and  sterilize  tools.

Wash  and  sterilize  tools  to  kill  any  germs  on  them
(see  page  59).

Get  rid  of  wastes  safely.

Throw  away  waste  products  carefully  to  prevent  people  in
the  community  from  getting  sick  from  the  germs  left  on
them  (see  page  67).

Remember:  Infection  can  spread  most  easily  when  a health  worker  is
caring  for  many  people.  For  example,  if  her  hands  are  not  clean  or  her
tools  are  not  sterile,  she  will  pass  germs  from  one  woman  to  another
to  another.  For  this  reason,  a woman  giving  birth  at  a hospital  or
maternity  center  with  many  other  women  has  more  risk  of  infection
than  a woman  giving  birth  at  home.

Adapt  this  book  to  work  for  you

This  chapter  contains  many  detailed  instructions  for
preventing  infection.  They  are  all  important,  but  they
may  not  all  be  possible.  You  will  have  to  decide
which  you  are  able  to  do,  or  if  there  are  ways  you
can  adapt  the  instructions  to  work  for  you.

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Prevent  infection  by  keeping  germs  away

Clean  your  hands  and
wear  protective  clothing

Wash  your  hands  often

Washing  your  hands  is  one  of  the  most  important  things  you
can  do  to  prevent  infection.  It  prevents  you  from  spreading
germs  to  another  person,  and  it  helps  protect  you  from  germs,
too.  If  you  can  do  nothing  else  to  prevent  infection,  you  must  wash  your  hands.

Wash  your  hands  with  soap  and  clean  water.  If  you  do  not  have  soap,  you  can
use  ash  (but  not  dirt!).  Be  sure  to  rinse  all  the  soap  or  ash  off.  When  you  wash  your
hands,  and  especially  when  you  rinse  them,  use  clean  water  that  is  flowing,  not
water  sitting  in  a bowl.  When  you  wash  your  hands  in  a bowl,  the  germs  that  come
off  into  the  water  will  get  back  onto  your  hands  again.

Wash  your  hands  each  time  before  you  touch  a woman's  body.  Wash  after  you
touch  her  body,  or  after  you  touch  anything  that  has  her  blood  or  fluid  on  it  (like
the  placenta).  Wash  before  you  put  on  gloves  and  after  you  take  gloves  off.  If  you
are  helping  more  than  one  woman  at  once,  like  at  a hospital,  it  is  very  important  to
wash  between  helping  each  person.

Normal  hand  washing  removes  most  germs.  But  sometimes  to  remove  more  germs,
you  should  wash  your  hands  for  a full  3 minutes,  and  scrub  under  your  fingernails.

How  to  do  a 3-minute  hand  wash

Before  you  start,  take  off  rings,  bracelets,  and  other  jewelry.

1

Wash  your  hands  and
arms  with  soap  and
clean  water  — all  the
way  up  to  your  elbows.

Make  sure  to  scrub  in
between  your  fingers.

Keep  scrubbing,  brushing,
and  washing  your  hands
and  arms  for  3 minutes!
Spend  most  of  this  time
on  your  hands.

Rinse
with  clean,
running  water.

If  you  have  a clean  brush,
scrub  your  fingernails.

Dry  your  hands  in  the  air
instead  of  using  a towel.
Do  not  touch  anything
until  your  hands  are  dry.

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Chapter  5:  Preventing  infection

Always  do  a 3-minute  hand  wr^u

before  you:

• touch  the  mothers  vagina

• do  a pelvic  exam  i

• deliver  the  baby

• sew  up  a tear

after  you:

• clean  up  after  the  birth

• touch  any  blood  or

other  body  fluids
• urinate  or  pass  stool

• insert  an  IUD  (see  Chapter  21)

• do  an  MVA  (see  Chapter  23)

Alcohol  and  glycerine  hand  cleaner

You  can  make  a simple  hand  cleaner  to  use  if  you  do  not  have  water  to  wash  your
hands.  When  used  correctly,  this  cleaner  will  kill  most  of  the  germs  on  your  hands.

Mix  2 milliliters  glycerine  with  100  milliliters  of  ethyl  or  isopropyl  alcohol
60%  to  90%.

To  clean  your  hands,  rub  about  5 milliliters  (1  teaspoon)  of  the  hand  cleaner
into  your  skin.  Be  sure  to  clean  between  your  fingers  and  under  your  nails.  Keep
rubbing  until  your  hands  are  dry.  Do  not  rinse  your  hands  or  wipe  them  with  a
cloth.

Clean  water

Throughout  this  book  we  talk  about  how  important  it  is  to  wash
your  hands  and  wash  your  tools.  But  the  water  you  use  must  be
clean  to  be  of  any  use.  If  the  water  in  your  community  may
carry  germs,  be  sure  that  water  is  boiled  before  using  it  to  ^
wash  your  hands  or  to  wash  tools  before  a birth.

Wear  gloves

Latex  and  other  plastic  gloves  protect

B women  from  any  germs  that
may  be  hiding  under  your
fingernails  or  on  your  skin.
They  also  protect  you  from

Plastic  bag  gloves

If  you  do  not  have  a a

getting  infections.  Wear  clean  gloves
whenever  you  touch  the  mothers
genitals,  or  any  blood  or  body  fluid.

or  if  you  are  touching  any  tools  that
have  been  sterilized,  you  must  wear
sterile  gloves.

If  you  are  doing  invasive  procedures,

gloves,  use  plastic  bags  Li/JLIa
that  have  been  washed
in  disinfectant  soap  instead.  Bags
are  harder  to  use  than  gloves,  but
they  are  better  than  nothing.

In  the  rest  of  this  book,  we  will
only  mention  gloves.  But  be  sure
to  use  plastic  bags  if  you  do  not
have  gloves.

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Prevent  infection  by  keeping  germs  away

How  to  put  on  sterile  gloves

1

2

Open  the  package  without  Carefully  wash  your

touching  the  gloves.  Do  hands.  Let  them  dry

not  touch  the  outside  of  a in  the  air.

sterile  glove  with  your

hand  or  it  will  not  be

sterile  anymore.

The  gloves  should  be
folded  out  at  the  cuff.

Pick  up  one  glove  under
the  cuff  on  the  inside  of
the  glove  and  slip  your
hand  into  it.  Do  not  touch
the  outside  of  the  glove.

Wiggle  your  hand  in
while  you  pull  with
your  finger  tucked
inside  the  glove.

Pick  up  the  second  glove
by  slipping  your  gloved
fingers  into  the  fold  of
the  cuff.  Slide  your  hand
into  the  glove.

Once  the  gloves  are  on,
do  not  touch  anything
that  is  not  sterile  — or
the  gloves  will  not  be
sterile  anymore  either!

Practice  with  the  same  pair  of  gloves  over  and  over  again  until  it  feels  easy.

Remember:

If  you  carefully  wash  and  put  on  and  then  scratch  your  glove  is  not

your  hands...  sterile  gloves  .. . your  head...  sterile  anymore!

Of  course,  when  you  touch  a woman  you  will  get  germs  on  your  gloves,  but  do
not  move  germs  from  one  part  of  her  body  to  another.  For  example,  if  you  touch  a
woman's  anus  where  there  are  many  germs,  do  not  put  your  fingers  inside  the
vagina  with  the  same  gloves.  Germs  from  the  anus  can  make  a woman  sick  if  they
get  into  the  vagina  or  womb.

After  you  use  a pair  of  gloves  one  time,  throw  them  away,  or  sterilize  them
before  you  use  them  again  (see  page  66).

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Chapter  5:  Preventing  infection

Protect  yourself  from  infection

Midwives  must  protect  themselves  from  germs  and  infection.  You  will  not  be  able  to
help  women  if  you  are  sick.  And  if  you  are  infected  with  dangerous  germs,  you  can
easily  spread  them  to  the  women  you  are  trying  to  help.

Some  germs  that  cause  serious  illnesses,  like  AIDS  and  hepatitis  B,  only  live  in
blood,  urine,  stool,  the  bag  of  waters,  and  other  body  fluids.  That  means  you  do  not
get  these  illnesses  just  by  touching  someone's  skin.  But  the  germs  that  cause  AIDS
and  hepatitis  B can  infect  you  if  an  infected  person's  blood  gets  into  a cut  or  opening
in  your  skin  — even  a cut  so  small  that  you  cannot  see  it  (see  page  99  for  all  the  ways
HIV  can  spread).  Keep  blood  and  other  body  fluids  off  your  clothing  and  skin,  and
if  they  do  get  onto  you,  wash  them  off  right  away  with  soap  and  water.

Wear  protective  clothing

You  do  not  need  expensive  equipment  to  keep  body
fluids  off  your  skin,  out  of  cuts,  and  out  of  your
mouth  and  eyes.  You  can  wear  an  apron  or  an  extra
shirt  to  keep  fluid  off  your  body.  Protect  your  eyes
with  eyeglasses  or  plastic  goggles.  Cover  your  feet
so  that  you  do  not  step  into  blood  or  other  fluids.

Wash  all  your  clothing  after  any  blood,  waters,  or  other
body  fluids  gets  on  it.  If  you  get  body  fluids  in  your  eyes
or  mouth,  rinse  them  for  several  minutes  with  clean  water
or  saline  (water  with  a little  salt  added).

If  you  do  not  have
clothing  made  to  protect
you  from  blood  and  fluids,
you  can  make  it  from
what  you  already  have.

56

Be  careful  with  needles

If  a syringe  is  used  to  give  an  injection,  or  a needle  was  used  for  sewing  a vaginal  tear,
the  needle  has  blood  on  it.  If  you  accidentally  stick  yourself  with  that  used  needle,  you
will  be  exposed  to  germs.  Carry  needles  carefully  with  the  point  away  from  your  body.
Do  not  leave  needles  lying  around.

Use  each  needle  only  once  and  then  throw  it  away  in  a box  like  the  one  on  page  68.
You  may  be  able  to  get  needles  that  can  only  be  used  once  and  do  not  need  a cap.  If  you
must  reuse  a needle,  put  the  cap  on  very  carefully  and  then  put  the  needle  in  a bucket
filled  with  bleach  solution  (see  page  57)  until  you  are  ready  to  clean  and  sterilize  it.

How  to  avoid  puncturing

Do  not  use  your  hand  to
put  the  cap  on  the  needle.

your  skin  with  a needle

Instead,  use  the  needle
to  pick  up  the  cap.

Note:  If  you  do  get  stuck  by  a needle,  immediately  wash  the  area  with
soap  and  water  or  alcohol  and  dispose  of  the  needle  properly  (see
pages  67  and  68).  Do  not  use  it  on  another  person.

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Clean  the  space  and  bedding

Clean  the  space  and  bedding
Clean  the  space

At  home

One  reason  that  birth  or  medical  procedures
can  happen  as  safely  in  a woman's  home  as
in  a medical  center  is  that  there  are  not  as
many  germs  in  a clean  house  as  in  a hospital.

But  the  home  should  still  be  cleaned  carefully  —
especially  the  area  where  the  baby  will  be  born  or  where  procedures  such  as  a pelvic
exam  or  IUD  insertion  will  be  done.

Sweep  these  areas  free  of  dust  and  dirt,  and  wash  surfaces  with  soap  and  water.
Put  your  tools  or  birth  kit  on  a clean  surface.

Move  animals  out  of  the  house  and  do  not  do  any  medical  procedures  in  places
where  animals  sleep  or  pass  stool,  or  where  people  urinate  or  pass  stool.  If  the  floor
in  the  house  is  made  of  animal  waste  (dung),  do  not  let  the  woman's  body  or  any
of  your  tools  touch  the  floor.  Dung  has  many  germs  in  it  that  can  easily  spread  to
pregnant  women.  You  can  cover  the  floor  with  clean  straw,  cloth,  or  plastic.

In  a hospital , maternity  center ; or  clinic

Be  extra  careful.  Germs  can  easily  be  passed  from  one  person  to  another.

After  each  birth,  wash  floors  and  surfaces.  If  possible,  use  a bleach
(sodium  hypochlorite)  solution  to  wash  the  floor.

How  to  make  a disinfecting  solution  of  5%  bleach

If  your  bleach  says:

5%  available  chlorine  10%  available  chlorine  15%  available  chlorine

use  undiluted,
straight  bleach

use  1 part  and  1 part
bleach  water

use  1 part  and  2 parts
bleach  water

Mix  just  enough  solution  for  1 day.  Do  not  use  it  again  the  next  day.
It  will  not  be  strong  enough  to  kill  germs  anymore.

If  you  do  not  have  bleach,  you  can  wash  the  floor  with:

• ethanol  (medical  alcohol)  70%

• isopropyl  alcohol  70%

• hydrogen  peroxide  6%

• soapy  water

• ammonia

(But  do  not  ever  mix
bleach  with  ammonia
— when  mixed  they
make  a poison.)

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Chapter  5:  Preventing  infection

Clean  or  sterilize  the  bedding

At  home

Wash  cloth  for  covering  the  bed  (bedding)  in
soap  and  water,  and  dry  it  thoroughly  by
hanging  it  in  the  sun  or  ironing  it.  Do  not  dry
bedding  on  the  ground;  it  will  pick  up  germs.

In  a hospital , maternity  center ; or  clinic

Bedding  must  be  sterilized  after  each  birth.  Use  one  of  these  methods  to  kill
the  germs:

• Wash  the  bedding  with  soap  or

and  water.  Then  boil  for  30
minutes.  Dry  thoroughly  in  a

• Wash  bedding  with  soap
and  water.  Then  use  a hot
iron  to  dry  it.

If  neither  of  these  methods  is  possible,  wash  the  bedding  in  soap  and  water  and
hang  it  in  the  sun  until  it  is  fully  dried.  Turn  the  bedding  so  the  sun  shines  on
both  sides,  and  take  care  to  keep  it  clean.

Store  bedding  to  keep  germs  away

If  you  are  not  going  to  use  the  bedding  right  away,  keep  it  clean  and  dry  until  you
are  ready  to  use  it.  Put  it  in  a clean  bag  or  wrap  it  in  clean  paper  and  store  it  in  a
clean,  dry  place.

Note:  Do  not  store  bedding  that  is  damp  or  wet.  Germs  will  come  back!

Other  kinds  of  underpadding

Sometimes  there  is  no  bed  or  bedding.  The  birth  or  procedure  happens  on  the
floor.  In  these  cases,  it  is  useful  to  have  some  kind  of  underpadding.  This  protects
the  baby  and  the  mother  from  the  germs  and  dirt  that
are  on  the  floor.  Find  a way  to  clean  the
underpadding  before  it  is  used.  For  example,
banana  leaves  can  be  washed  with  a
disinfectant  solution,  and  then  smoked  or
dried  in  the  sun.  Cloth  rags  or  sacks  can  be
boiled  and  then  dried.

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Clean  and  disinfect  tools

Clean  and  sterilize  tools

All  the  tools  used  at  a birth,  exam,  or  procedure  must  be  cleaned  and  sterilized.
Cleaning  and  sterilizing  the  tools  gets  rid  of  germs.  This  protects  women  from
getting  sick.

1.  Soak  your  tools

Tools  that  have  been  used  must  be  soaked  for  at  least  20  minutes  in  bleach
solution  (see  page  57).

2.  Clean  your  tools

All  tools  and  equipment  you  use  at  a birth  or  a procedure
must  be  clean.  Wash  them  well  after  each  birth,  using  a
brush  to  remove  any  blood  or  dirt  in  the  hinges  or  rough
edges  of  your  tools.  Clean  off  any  rust,  and  get  rid  of  tools
that  are  dull  or  damaged.  To  protect  yourself,  wear  heavy
gloves  when  you  clean  your  tools.

After  everything  is  washed,  any  tools  that  you  use  inside
a woman's  body  must  also  be  sterilized  to  kill  germs.

3.  Sterilize  your  tools

To  sterilize  means  to  kill  all  the  germs  on  something.  If  your  tools  are  sterilized,
they  will  not  spread  germs  to  women  when  you  use  them.  This  will  protect  women
from  getting  infections.

Carefully  wash
all  the  dirt  off

What  do  we  mean  when  we  say  "sterile"?

Sterilize  means  kill  all  the  germs  that  cause  infections.  To  sterilize  a tool
you  must  use  baking  or  pressure  steaming.

Disinfect  means  to  kill  most  of  the  germs  that  cause  infections.  Some  soaps
and  cleaning  products  are  called  "disinfectant."  But  to  disinfect  medical  tools
or  instruments  you  cannot  simply  clean  something  with  a disinfectant  soap
— you  must  boil,  steam,  or  soak  the  tool  in  disinfectant  chemicals.  This  kind
of  disinfection  is  called  High  Level  Disinfection  (HLD).

All  the  procedures  in  this  book  can  be  done  safely  with  tools  that  are
either  sterile  or  HLD.  To  be  simple,  we  only  use  the  word  "sterilize"  or
"sterile"  throughout  the  book.  But  any  time  we  say  that  a tool  should  be
sterile,  we  really  mean  it  can  be  sterile  or  HLD.

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Chapter  5:  Preventing  infection

Sterilize  everything  that  will  go  inside  a woman's  body,  will  cut  her  skin,  or  will
be  used  to  cut  the  cord  at  birth.

Sterilize  these  items:

• syringes  and  needles

• scissors  or  razor  blade  for  cutting  the  cord

• materials  for  sewing  tears

• clamps  or  hemostats

• gloves

• gauze

• compress  cloths

• bulb  syringe  or  mucus  trap

• MVA  cannula
(see  page  420)

• speculums,  in  some  cases

Note:  You  do  not  need  to  sterilize  tools  that  are  used  only  on  the
outside  of  the  body.  Stethoscopes,  measuring  tape,  and  blood  pressure
cuffs  must  be  clean  but  do  not  need  to  be  sterile.

When  you  sterilize  a tool,  the  germs  on  it  are  killed
and  it  is  safe  to  use.  But  if  that  tool  touches  anything
(including  the  bed,  a table,  or  you!)  it  is  no  longer  sterile.
Germs  from  whatever  it  touched  are  on  it,  and  those
germs  can  cause  an  infection  when  the  tool  is  used.

The  next  few  pages  explain  5 different  ways  to  sterilize  your  tools:
baking,  pressure  steaming,  boiling,  steaming,  and  soaking  in  chemicals.

Baking  and  pressure  steaming  are  best  — they  kill  the  most  germs.  If  you  cannot
use  either  of  those  methods,  boiling,  steaming,  or  using  disinfectant  chemicals
is  fine.  Use  the  ways  that  work  best  for  you.

WARNING!  If  you  cannot  sterilize  your  tools,  then  do  not
use  them.  Unsterilized  tools  will  do  more  harm  than  good.

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Clean  and  disinfect  tools

Baking

Use  baking  to  sterilize  metal  tools,  and
string  for  tying  the  cord.  Do  not  bake
rubber  or  plastic.  It  will  melt.

Wash  and  rinse  all  the  tools  well,  then  put  them  into  4 layers  of
clean  cloth  or  heavy  paper.  Wrap  the  cloth  up  around  the
instruments  and  tie  it  shut.

Put  the  packet  of  tools  or  string  into  a container  or  on  a pan.

Bake  on  a medium-high  heat  (1 70°C  or  340°F)  for  1 hour.

This  is  a little  longer  than  it  takes  to  bake  a big  potato  or  yam.  If  you  cannot
make  your  oven  hot  enough,  bake  items  longer.

Let  the  packet  cool,  then  store  it  in  a clean,  dry  place.

Pressure  steaming

Use  pressure  steaming  to  sterilize  metal  tools  or  rubber
or  plastic  equipment.

Some  clinics  and  hospitals  have  a machine  for
sterilizing  called  an  autoclave.  Autoclaves  sterilize
instruments  using  pressure  and  steam.  If  you  have  a
pressure  cooking  pot,  you  can  sterilize  your  tools  in  the
same  way  that  an  autoclave  does.

Put  a steamer  basket  and  water  in  the  pressure  cooking  pot.  Put  your  tools
into  the  steamer,  close  the  lid  on  the  pot,  and  put  the  pot  on  a flame  to  boil

After  it  comes  to  a boil,  cook  at  1 5 or  20  pounds  of  pressure  for  20  minutes.

After  sterilizing  tools,  let  them  dry.  Do  not  touch  them,  or  they  will  not  be
sterile  anymore!

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Use  sterilized  tongs,  chopsticks,  or  spoons  to  pick  the  tools  out  of  the  pot.  Move
them  directly  to  a sterilized  container.  Remember,  if  the  tool  touches  anything,
including  your  hands,  it  is  no  longer  sterile.

Let  the  tools  dry  in  the  sterilized  container.  Cover  the  container
/l;  m with  a sterilized  cloth  or  paper  to  keep  dust  out.

When  the  tools  are  all  dry,  put  the  lid  on  the  container
and  seal  it  with  tape  or  some  other  material  to  keep  the
germs  out.

Boiling

Use  boiling  to  sterilize  metal  tools,  rubber  or
plastic  equipment  (like  mucus  bulbs),  and  cloth

After  you  wash  and  rinse  your  tools,  cover  with
water  and  boil  for  20  minutes.

Start  counting  the  20  minutes  when  the  water
starts  boiling.

Use  sterilized  tongs,  chopsticks,  or  spoons  to  pick  the  tools  out  of  the  pot.  Move
them  directly  to  a sterilized  container.  Remember,  anything  you  touch  is  no  longer
sterile.

Steaming

Use  steaming  to  sterilize  metal  tools,
gloves,  plastic  equipment,  and  other  tools.

A steaming  pot  has  3 parts  that
fit  together  tightly:  one  pot  on  the  bottom
to  boil  water  in,  one  pot  in  the  middle  that
has  holes  in  its  bottom,  and  a lid.

Boil  a little  water  in  the  bottom  pot.  Put  the  tools  into
the  steamer  pot  with  the  holes.  Cover  with  the  lid.

Steam  over  boiling  water  for  at  least  20  minutes.

Start  counting  the  20  minutes  when  the  water
starts  boiling.

mm>)

steaming  pot  method

a lid

one  pot
with  holes
in  the
bottom

one  pot  on
the  bottom
to  boil  water
in

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Clean  and  disinfect  tools

Wait  for  the  tools  to  dry,  and  then  use  sterilized  tongs  to
move  the  tools  from  the  steamer  into  a sterilized  container,
and  seal  the  container.

Steaming  uses  less  water  than  boiling,  and  tools  that  are
steamed  do  not  get  dull  or  broken  as  quickly  as  tools  that
are  boiled.

A method  from  the  Philippines

The  Medical  Mission  Sisters  in  the  Philippines  have
developed  a method  to  sterilize  tools  with  steam:

1.  Put  your  clean  tools  into  a metal  tray.

Place  the  tray  in  a cooking  pan.

Fill  the  pan  with
water  until  it
reaches  halfway  up  the  tray.

water  level

Cover  the  pan  with  8 layers  of  clean
green  banana  leaves.  Bind  the  leaves  tightly
in  place  with  strips  of  banana  leaf  or  bark.
Be  careful  not  to  spill  water  into  the  tray
when  you  do  this.

Put  the  pan  on  a low  fire  and  boil  for
about  1 hour.

6.  Throw  away  the  top  layer  of  the  leaves.
You  can  use  one  of  the  inner  layers  to
put  your  instruments  on.

Using  chemicals

Some  people  use  chemicals  to  sterilize  metal,
rubber,  or  plastic  tools  and  equipment.  We  do
not  recommend  using  chemicals  to  sterilize.

Most  chemicals  used  to  sterilize  are  poisonous.

They  poison  the  ground  and  the  water  when  they
are  thrown  away.  They  are  poisonous  to  the
people  who  work  in  factories  making  them,  and
they  are  poisonous  to  the  people  who  use  them  to  clean  tools.

But  some  tools  can  only  be  sterilized  with  chemicals.

Thermometers  and  some  kinds  of  gloves  cannot  be  baked,  boiled,  or  steamed.

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Chapter  5:  Preventing  infection

If  you  do  need  to  use  chemicals:

• mix  up  the  bleach  solution  on  page  57.

or  If  you  do  not  have  bleach,  use  one  of  the  following  chemicals:

• ethanol  (medical  alcohol)  70%

• isopropyl  alcohol  70%

• hydrogen  peroxide  6%

or  If  you  cannot  get  any  of  these  chemicals,  you  can  use:

• strong  drinking  alcohol  like  gin,  or  a strong  local  brew.

Be  sure  that  all  of  your  tools  are  very  clean  before  sterilizing  them  with  chemicals.
Even  a little  blood  or  body  fluid  left  on  the  tool  can  stop  the  chemicals  from
working.  Do  not  use  chemicals  to  sterilize  tools  that  will  go  inside  the  womb.

Soak  in  bleach  or  disinfecting  chemicals  for  at  least  20  minutes.

or

Soak  in  strong  drinking  alcohol  for  a whole  day.

After  soaking,  pour  the  chemicals  off  and  let  the  tools  dry.

WARNING!  Glutaraldehydes  and  formaldehyde  are  chemicals
that  we  think  are  too  dangerous  to  ever  use.  Many  clinics  and
hospitals  use  these  to  sterilize,  but  they  are  very  toxic.
Formaldehyde,  for  example,  causes  cancer.  Try  to  find  a
different  way  to  sterilize.

If  you  use  chemicals,  keep  them  off  your  skin,  and  wear  gloves  when  you  use
them.  Get  rid  of  chemicals  carefully.  You  may  have  to  dump  bleach  or  other
chemicals  into  a latrine  to  be  sure  animals  and  children  do  not  drink  it.

Storing  tools  and  supplies

At  some  births  there  will  be  plenty  of  time  to  sterilize
your  tools  and  equipment  at  the  mother's  house.  But  at
other  births,  you  may  not  have  time.  For  this  reason,  try
to  sterilize  your  tools  and  equipment  at  home  and  keep
them  in  a sterilized  container  in  your  kit.  A metal
box  or  pot  with  a tight-fitting  lid  is  best.

Use  any  of  the  above  methods  to  sterilize  a
container  and  tools  to  move  equipment.

Do  not  touch  the  inside  of  the  container.

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Clean  and  disinfect  tools

If  you  cannot  get  such  a container,  wrap  the  tools  and  equipment  in  4 layers  of
cloth  or  heavy  paper  before  sterilizing  them.  Then  keep  the  sterilized  tools
wrapped  up  until  you  are  ready  to  use  them.  (You  can  only  use  cloth  or  heavy
paper  to  wrap  your  tools  if  you  are  sterilizing  by  baking.)

Remember  that  germs  grow  in  moisture,  and  they  will  come  back  if  the
instruments  are  put  away  while  they  are  wet.  But  if  you  are  going  to  use  the  tools
right  away,  it  is  OK  to  use  them  when  they  are  wet.  Germs  need  time  to  grow.

Some  equipment  needs  special  care

Sterile  packets

Gauze,  compresses,  gloves,  and  other
equipment  sometimes  come  in  sterile
packets.  Because  the  inside  of  the
packet  is  sterile  too,  you  can  use  this
equipment  directly  out  of  the  packet.

But  remember:  once  you  take
something  out  of  its  sterile  packet  Thls  glove  IS  stenle-
and  use  it,  or  if  the  packet  gets  wet  or
gets  holes  in  it,  the  equipment  is  not  sterile  anymore.

tear  in  package

Things  in  sterile  packets  are  often  meant  to  be  used  only  once  and  then  thrown
away  (disposable).  But  some  of  these  things  can  be  used  again  if  they  are  carefully
cleaned  and  sterilized  before  each  use.  Gloves  can  be  boiled  or  steamed.  Gauze  and
compresses  can  be  washed  and  then  boiled  or  baked.

Thermometers

Wash  the  thermometer  in  soap  and  rinse  with  cool,  ^ r~ ,,  tL  ^

clean  water  before  and  after  you  use  it.  Do  not  use
hot  water  because  the  thermometer  may  break.

After  washing,  it  is  best  to  soak  the  thermometer  in  alcohol  for  20  minutes.  You
can  use  ethyl,  isopropyl,  or  medical  alcohol  (ethanol).  Do  not  reuse  the  alcohol.
Rinse  the  thermometer  in  clean  water  before  you  use  it  again.

Razor  blades

Razor  blades  for  cutting  cords  often  come  inside  of  a sterile  packet.  To  keep  the
packet  sterile,  wrap  it  in  clean  paper  or  cloth,  or  keep  it  in  a clean  dry  box.  If  the
packet  gets  wet  or  dirty,  it  is  not  safe  to  use  the  razor  blade
unless  you  sterilize  it  again.

Try  not  to  reuse  razor  blades  — but  if  you  do,  they  must  be
sterilized  first.  Razor  blades  can  be  sterilized  by  any  method.

litEVES  V

1 l ft  li  t

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Chapter  5:  Preventing  infection

Gloves

Most  plastic  gloves  can  be  boiled  or  steamed,  but  some  will  fall  apart  in  the  water.
Get  strong  gloves  that  can  be  boiled  and  reused  a few  times.

Before  boiling  or  steaming  gloves,  turn  the  cuff  inside
out.  After  sterilizing  a glove,  touch  only  the  inside  part  of
it.  If  you  touch  the  outside,  it  will  not  be  sterile  anymore.

If  the  gloves  you  have  cannot  be  boiled,  wash  them
carefully  and  soak  them  in  bleach  or  medical  alcohol.  Then
Only  touch  the  rinse  them  in  clean  water  before  using  them  again.

inside  of  the  glove.

Mucus  bulb  (bulb  syringe)  \

When  you  wash  out  a mucus  bulb,  make  sure  to  fill  it  with  soapy  water
and  then  squeeze  the  water  out.  Do  this  several  times.  Then  rinse  it  out  well.

If  you  sterilize  the  mucus  bulb  by  boiling,  make  sure  to  let  water  into  the
inside  of  the  bulb  before  boiling  and  then  squeeze  out  all  the  water  afterward.

Needles

Many  people  get  sick  with  serious  illnesses  like  hepatitis  or  HIV  from  using
unsterilized  needles.

Reusable  syringes  and  disposable  syringes

Reusable  syringes  can  be  used  again  and  again.  Reusable  syringes  make  less  waste
and  can  save  money,  but  they  must  be  washed  very  carefully  and  sterilized  after
every  use.

Disposable  syringes  are
made  to  be  thrown  out
after  one  use.  Some
disposable  syringes  can  be
taken  apart,  boiled  or
steamed,  and  reused  several
times.  But  we  do  not
recommend  this,  because
needles  that  are  not
completely  sterilized  can
spread  disease.

Never  reuse  a needle
or  syringe  without
cleaning  and
sterilizing  it  first!

How  to  wash  and  sterilize  a syringe

and  needle  for  reuse:

1.  Put  on  a pair  of
heavy  gloves  to
protect  your  hands
from  germs.

2.  Draw  5%  bleach  solution
(see  page  57)  up  through  the
needle  into  the  syringe  barrel.

3.  Squirt  out  the  bleach  solution.

4.  Repeat  several  times.  Rinse
everything  several  times  with  clean  water.

5.  Take  the  syringe  and  needle  apart  and
boil  or  steam  them.  (See  page  62.)

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Get  rid  of  wastes  safely

Remember:

If  you  take  a sterile  syringe  and  put  it  in  it  is  not  sterile  anymore,

out  of  boiling  water . . . your  pocket . . . Instead,  it  is  dangerous!

Get  rid  of  wastes  safely

There  are  three  different  kinds  of  waste  after  a birth  or  procedure:

body  wastes  sharp  wastes  other  wastes

"A

like  blood,

like  needles  for

like  used

stool,  or  placenta

sewing  or  syringes

plastic  gloves

These  wastes  carry  germs  and  can  spread  infections  to  you  and  to  people  in  the
family  and  community.  Wear  gloves  when  you  touch  wastes,  and  get  rid  of  them
carefully.

Body  wastes

The  simplest  way  to  dispose  of  body  wastes  is  to  put  them  in  a latrine  or  to
bury  them  deep  in  the  ground.

In  many  communities,  families  bury  the  placenta,  sometimes  with  other  special
objects.  Burying  the  placenta  is  an  important  ritual  for  many  people,  and  is  also  a
way  to  protect  the  community  from  germs  that  may  grow  in  the  placenta.

Sharp  wastes

Sharp  wastes  must  be  put  into  a container  so  they  will  not
injure  anyone  who  finds  them.  A container  made  of  metal  or
heavy  plastic,  with  a lid  or  tape  to  close  it,  works  well.

When  the  container  is  half  full,  add  bleach  if  possible,  then
seal  it  closed  and  bury  it  deep  in  the  ground  (see  page  68).

1 »*4ll  l if  it  &

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Chapter  5:  Preventing  infection

Make  a box  to  dispose  of  needles  safely

Find  a metal  or  hard  plastic  box.  Make  a long
hole  in  the  lid  of  the  box  that  is  wide  on  one
side  and  gets  narrower  on  the  other  side.

When  you  have  finished  using  a
disposable  syringe,  put  the  needle
into  the  box  and  slide  it  down  to
the  narrowest  point.

Then  pull  up  on  the  syringe
and  the  needle  will  fall  off  into
the  box.  The  plastic  syringe  can

When  the  box  is  half  full,  pour  5%  bleach  solution  into  the  box,  seal  it
closed,  and  then  bury  it  deep  in  the  ground.

Other  wastes

Other  wastes,  like  plastic  gloves,  syringe  barrels,  or  cloth  soaked  in  blood,  should
be  sterilized  and  then  buried  deep  in  the  ground.  You  can  sterilize  them  by
soaking  them  in  bleach  for  20  minutes.

WARNING!  Do  not  burn  plastic  gloves,  syringes,  or  any
other  plastics.  Burning  plastic  wastes  is  dangerous  — when
plastic  burns,  it  makes  smoke  and  ash  that  is  very  poisonous.

Burying  wastes

Find  a place  away  from  where  people  get  their
drinking  water  and  away  from  where  children
play.  Dig  a safe  waste  pit  to  bury  wastes.

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Get  rid  of  wastes  safely

A safe  waste  pit

1.  Dig  a pit  1 to  2 meters  wide  and  2 to  5 meters  deep.  The  bottom  of  the  pit
should  be  at  least  1 meters  above  the  water  table.

2.  Line  the  inside  of  the  pit  with  a layer  of
clay  or  rocks  at  least  10  centimeters  thick.

3.  Build  up  a ridge  of  earth  around  the
top  of  the  pit  to  prevent  surface  water
from  running  in.

4.  Build  a fence  around  the  area  where  the
pit  is  located  to  keep  animals  out.

Each  time  waste  is  put  in  the  pit,  cover  the  waste  with  10  centimeters  of  soil,  or
a mix  of  soil  and  lime.  Lime  helps

disinfect  the  waste,  and  will  also  keep  animals  away  while  the  pit  is  in  use.

When  the  waste  rises  to  V2  meter  from  the  surface,  cover  it  with  V2  meter  of  soil
and  seal  it  with  a layer  of  concrete  at  least  90  centimeters  thick.  If  the  pit  is  used
only  for  medical  waste  and  not  for  regular  garbage,  it  will  not  fill  up  too  quickly.

Garbage  dumps

When  wastes  are  sent  to  a garbage  dump,  they  can  spread  infections  there.

In  many  places,  people  pick  through  garbage  to  find  things  to  sell,  like  used
syringes.  This  is  dangerous  for  the  people  picking  through  the  garbage,  and
for  the  people  who  buy  the  syringes  to  use  them  again.

When  a syringe  is  not  usable  anymore,  dispose  of  it  safely.  If  you  must
send  needles  to  the  garbage  dump,  sterilize  them  first,  and  seal  them  in  a
box  or  tin.

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Pregnancy

INTRODUCTION

All  women  need  care  and  attention  during
pregnancy.  This  care  is  usually  called
prenatal  or  antenatal  care.  Prenatal  care
helps  pregnant  women  be  healthier
and  have  fewer  problems  in  birth.

Prenatal  care  should  come  from  the
woman  herself,  from  her  family  and
the  community,  and  from  a midwife
or  someone  else  who  is  experienced
in  helping  pregnant  women.

In  some  places,  midwives  only  care  for  women  when  they  are  in
labor  or  giving  birth,  not  during  pregnancy.  This  may  be  because
most  of  the  time,  people  only  go  to  a healer  or  doctor  when  they  are
sick  or  if  something  is  wrong.  Pregnancy  is  usually  normal  and
healthy,  so  people  may  not  think  that  prenatal  care  is  important.  But
most  midwives  know  that  women  who  have  good  care  during
pregnancy  are  more  likely  to  have  safer  births  and  healthier  babies.

Care  in  pregnancy  has  2 purposes:

1.  Observing  and  listening  to  the  pregnant  woman
by  checking  her  body  for  healthy  signs  and  warning
signs  and  by  asking  her  about  problems  or  listening
to  her  questions.

2.  Teaching  a woman  how  to  have  a healthier
pregnancy  (for  example,  how  to  eat  a healthy  diet
and  how  to  avoid  harmful  things).

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Midwives  should  start  prenatal  care  as  soon  as  a woman  knows
she  is  pregnant,  and  should  examine  the  woman  regularly  during
the  pregnancy.  We  call  these  meetings  "checkups."  If  possible,
every  woman  should  have  at  least  4 checkups.

Doing  more  checkups  will  give  you  more  chances  to  share
important  information  and  to  prevent  health  problems.  And  any
woman  who  has  warning  signs  should  have  checkups  more  often.

This  section  is  divided  into  3 different  chapters:

• Chapter  6 explains  the  changes  a woman  may  go  through
in  pregnancy.

• Chapter  7 explains  how  to  learn  about  a woman's  health  history
during  the  first  checkup.

• Chapter  8 explains  how  to  check  a woman  for  healthy  signs
and  warning  signs  at  each  checkup.

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Chapter  6

Common  changes  in  pregnancy

In  this  chapter:

Changes  in  eating  and  sleeping

Upset  stomach  (nausea)  and
dislike  of  some  foods

Food  cravings

Burning  or  pain  in  the  stomach  or
between  the  breasts  (heartburn) . . .

Body  changes  and  discomforts

Swollen  breasts

Swollen  feet

Swollen  veins  (varicose  veins)

Constipation

(difficulty  passing  stool)

Hemorrhoids  (piles)

Needing  to  urinate  often

Discharge

(wetness  from  the  vagina)

Difficulty  getting  up  and  down

Shortness  of  breath

Feeling  hot  or  sweating  a lot

Sleepiness

73

Difficulty  sleeping

74

74

76  The  mask  of  pregnancy

76  Purple  spots  on  the  skin  ....
76  Aches  and  pains  in  the  joints

Sudden  pain  in  the  side  of

76  the  lower  belly

77  Cramps  in  early  pregnancy.  .

77  Baby's  kicks  hurt  the  mother

Back  pain

77

' / Leg  cramps

Headaches

70

Other  pains

78

73

75

75

76

79

79

79

79

79

80
80
80
81
81

Changing  feelings  and  emotions

Sudden  changes  in  feelings 82

Worry  and  fear 82

Strange  dreams  and  nightmares 82

82

Forgetfulness 83

Feelings  about  sex 83

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Common  changes
in  pregnancy

During  pregnancy  a woman's  body  changes.  These  changes  can  sometimes  be
uncomfortable,  but  most  of  the  time  they  are  normal.  In  this  chapter,  we  describe
some  of  these  changes,  and  discuss  ways  to  help  women  feel  better.  We  also
explain  how  to  tell  when  a woman's  discomfort  may  be  a sign  that  something
dangerous  is  happening  with  her  pregnancy.

There  are  many  ideas  about  how  to  treat  the  discomforts  of  pregnancy.  We
cannot  explain  all  of  these  ideas  here.  If  you  know  remedies  or  treatments  for  these
problems  which  we  do  not  explain,  use  the  remedies  that  work  for  you.  We  do  not
have  all  the  answers.  But  use  the  ideas  on  page  19  to  help  you  decide  if  remedies
are  helpful  or  if  they  may  be  harmful.  Not  all  remedies  work.

Changes  in  eating  and  sleeping

Upset  stomach  (nausea)  and  dislike  of  some  foods

Many  women  have  nausea  in  the  first  months  of  pregnancy.  Sometimes  it  is
called  morning  sickness.  No  one  knows  for  sure  what  causes  morning  sickness,  but
for  many  women,  the  way  they  eat  affects  it.  If  the  nausea  is  mild,  encourage  the
woman  to  try  any  of  these  remedies:

• Eat  a food  that  has  protein  before  bed  or
in  the  night.  Some  good  foods  with
protein  are  beans,  nuts,  and  cheese.

• Eat  a few  crackers,  dry  bread,  dry
tortillas,  dry  chapatis,  or  other  grain
food  when  she  first  wakes  up  in  the
morning.

• Eat  many  small  meals  instead  of  2 or  3 larger  ones,  and  take  small  sips
of  liquid  often.

• Take  50  milligrams  vitamin  B-6,  2 times  each  day.  (Do  not  take  more.)

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pregnancy

Chapter  6:  Common  body  changes  in  pregnancy

• Use  acupressure  to  relieve  nausea.  Find  the  spot
3 fingers  above  the  wrist  between  the  2 tendons  on
the  inside  of  the  woman's  arm.  Press  on  this  spot, —
moving  your  finger  in  small  circles.  Press  firmly  but
not  hard  enough  to  hurt.  If  acupressure  is  going  to
help,  the  woman  should  start  to  feel  better  within  5 minutes.

• Drink  a cup  of  ginger,  mint,  or  cinnamon  tea
2 or  3 times  a day,  before  meals.  To  make  mint  or
cinnamon  tea,  put  a teaspoon  of  mint  leaves  or  a stick  of
cinnamon  in  a cup  of  boiled  water.  Let  the  tea  sit  for  a few
minutes  before  drinking  it.  To  make  ginger  tea,  boil
crushed  or  sliced  ginger  root  in  water  for  at  least  15
minutes.

A pregnant  woman  may  suddenly  dislike  a food  that  she  usually  likes.  It  is  OK
not  to  eat  that  food,  and  she  will  probably  begin  to  like  it  again  after  the  birth.  She
should  be  careful  that  the  rest  of  her  diet  contains  a lot  of  nutritious  food.

Food  cravings

A food  craving  is  a strong  desire  to  eat  a
not  food  at  all,  like  dirt,  chalk,  or  clay.

If  a woman  gets  a craving  for
nutritious  foods  (like  beans,  eggs,
fruits,  and  vegetables),  it  is  OK  for  her
to  eat  as  much  as  she  wants.  But  if  she
wants  a lot  of  "junk  food"  (like  candy,
soda,  or  packaged  snacks)  she  should
eat  nutritious  food  first.

A woman  who  craves  things  that  are
not  food,  like  dirt  or  clay,  should  not
eat  them.  They  may  poison  her  and  her
baby.  They  may  also  give  her  parasites,
like  worms,  that  can  make  her  sick.
Encourage  her  to  eat  iron-rich  foods
(see  page  36)  and  calcium-rich  foods
(see  page  38)  instead.

certain  food,  or  even  something  that  is

I just  want  \
to  eat  clay.

You  may  need  more  calcium '
and  iron.  Try  eating  green
vegetables , nuts , seeds , or
beans  instead.  Dirt  and  clay
can  give  you  parasites  ana
make  you  sick.  ,

Burning  or  pain  in  the  stomach  or  between  the  breasts
(heartburn)

A burning  feeling  or  pain  in  the  stomach  or  between  the  breasts  is  called
indigestion  or  heartburn.  Heartburn  happens  because  the  growing  baby  crowds
the  mother's  stomach  and  pushes  it  higher  than  usual.  The  acids  in  the  mother's
stomach  that  help  digest  food  are  pushed  up  into  her  chest,  where  they  cause  a
burning  feeling.  This  is  not  dangerous  and  usually  goes  away  after  the  birth.

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Changes  in  eating  and  sleeping

Here  are  some  things  a woman  can  try  to  make  herself  more  comfortable:

Keep  her  stomach  less  full  by  eating  smaller
meals  more  often  and  by  eating  foods  and
drinking  liquids  separately.

Avoid  eating  spicy  or  greasy  foods,  drinking
coffee,  or  smoking  cigarettes  — all  of  which  can
irritate  the  stomach.

Regularly  eat  papaya  or  pineapple,  which  have
enzymes  that  help  the  stomach  digest  food.

Keep  her  head  higher  than  her  stomach  when
lying  down  or  sleeping.  This  will  keep  her
stomach  acids  in  her  belly  and  out  of  her  chest.

As  the  baby
grows,  he
pushes  the
woman's
stomach  up.

• Calm  the  acids  in  the  stomach  by  drinking  milk  or  taking  a low-salt  antacid
that  contains  no  aspirin.  (Antacids  are  not  dangerous  but  they  cost  money
and  they  make  it  harder  for  the  body  to  use  nutrients  from  food.  Try  other
methods  before  using  antacids.)

Sleepiness

Some  pregnant  women  feel  sleepy  much  of  the  day.  This  is  most
common  during  the  first  3 months.

It  is  normal  for  pregnant  women  to  feel  sleepy.  Their  bodies
are  telling  them  to  slow  down  and  rest.  But  if  a woman  also  feels
weak,  she  may  have  other  problems,  like  a sickness,  depression
(see  page  274),  or  anemia  (see  page  116).

Difficulty  sleeping

If  a woman  cannot  sleep  because  she  is  uncomfortable  or  restless,  it  may  help  if:

• she  lies  on  her  side  with  something
comfortable  between  her  knees  and  at
her  lower  back.  She  can  use  a pillow,  a
rolled-up  blanket,  banana  leaves,  or
some  other  padding.

• someone  gives  her  a massage.

• she  drinks  herbal  teas  that  help  her  sleep.

Fighting,  worry,  and  unhappiness  in  a woman's  house  or  family  can  make  it
difficult  for  her  to  sleep.  If  possible,  a family  should  avoid  arguing  before  going
to  sleep.

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Chapter  6:  Common  body  changes  in  pregnancy

Body  changes  and  discomforts

Swollen  breasts

A woman's  breasts  get  bigger  during
pregnancy  because  they  are  getting  ready
to  make  milk  for  the  baby.  Sometimes  the
breasts  are  also  itchy  or  sore.

During  the  last  months  of  pregnancy,  a watery,  yellowish
fluid  may  leak  out  of  the  nipples.  This  is  normal.  The  fluid  is
colostrum  — the  first  milk  for  the  baby.

Swollen  feet

Swelling  of  the  feet  is  very  common,  especially  in  the  afternoon  or  in  hot  weather.
Swelling  of  the  feet  is  usually  not  dangerous,  but  severe  swelling  when  the  mother
wakes  up  in  the  morning,  or  swelling  of  the  hands  and  face  anytime,  can  be  signs
of  pre-eclampsia  (see  page  125).

Swelling  in  the  feet  may  improve  if  the  woman  puts  her  feet  up  for  a few
minutes  at  least  2 or  3 times  a day,  eats  fewer  packaged  foods  that  are
very  salty,  and  drinks  more  water  or  fruit  juices.

Swollen  veins  (varicose  veins)

Swollen  blue  veins  that  appear  in  the  legs  or  on  the  woman's
genitals  are  called  varicose  veins.  Sometimes  these  veins
hurt.  If  the  swollen  veins  are  in  the  legs,  they  may  feel
better  if  the  mother  puts  her  feet  up  often.  Strong
stockings  or  elastic  bandages  may  also  help.

If  the  swollen  veins  are  around  the  genitals,
they  can  cause  bleeding  problems  if  they  tear
during  birth.  Putting  a cool  cabbage  leaf  on  the
genitals  may  help.

Constipation  (difficulty  passing  stool)

Some  pregnant  women  have  difficulty  passing  stool.  This  is  called  constipation.
To  prevent  or  treat  constipation,  a woman  should:

• eat  more  vegetables  and  fruits.

• eat  whole  grains  (brown  rice  and  whole  wheat
instead  of  white  rice  or  white  flour).

• drink  at  least  8 cups  of  clean  water  a day.

• walk,  move,  and  exercise  every  day.

Home  or  plant  remedies  that  soften  the  stool  or  make  it  slippery  (like  remedies
made  from  psillium  seed  or  certain  fruits  or  fiber  plants)  may  also  help.

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Body  changes  and  discomforts

WARNING ! Pregnant  women  should  not  take  medicines  called
laxatives  or  purgatives  for  constipation.  These  work  by  making
the  bowels  tighten  or  contract  — and  they  may  cause  labor  to
start  too  soon.  Some  can  harm  the  baby.

Also,  pregnant  women  should  not  wash  out  the  bowels  with
water  (enema).  This  could  also  start  labor  too  soon.

Hemorrhoids  (piles)

Hemorrhoids  are  swollen  veins  around  the  anus.  They  may  burn,  hurt,  or  itch.
Sometimes  they  bleed  when  the  woman  passes  stool,  especially  if  she  is  constipated.
The  woman  should  try  to  avoid  getting  constipated  by  eating  a lot  of  fruit  and
vegetables  and  drinking  plenty  of  fluids.

Sitting  or  standing  a lot  can  make  hemorrhoids  worse.  But
sitting  in  a cool  bath  or  lying  down  can  help.  Some  women  say
it  helps  to  soak  a clove  of  garlic  in  vegetable  oil  and  then
insert  it  into  the  anus.

If  you  have  heard  of  other  remedies,  ask  an  experienced
health  worker  whether  they  are  safe.  Some  remedies  are
dangerous  for  pregnant  women  and  may  hurt  the  baby.

Pregnant  women
need  to  urinate
much  more  often.

Needing  to  urinate  often

Needing  to  urinate  (pee)  often  is  normal,  especially  in  the  first
and  last  months  of  pregnancy.  This  happens  because  the
growing  womb  presses  against  the  bladder  (the  place  where  the
body  stores  urine).  It  is  so  common  that  some  midwives  joke:

"A  man  who  cannot  find  his  pregnant  wife  should  wait  near  the
place  where  she  urinates.  If  she  is  not  there,  she  will  be  soon! "

If  urinating  hurts,  itches,  or  burns,  the  woman  may  have
a bladder  infection  (see  page  128)  or  a vaginal  infection
(see  Chapter  18).  Be  sure  to  treat  these  infections  right  away  —
they  can  cause  early  labor  and  other  problems.

Discharge  (wetness  from  the  vagina)

Discharge  is  the  wetness  all  women  have  from  the  vagina.  A woman's  body  uses
this  discharge  to  clean  itself  from  the  inside.  For  most  women  the  discharge
changes  during  their  monthly  cycle.  Pregnant  women  often  have  a lot  of
discharge,  especially  near  the  end  of  pregnancy.  It  may  be  clear  or  yellowish.

This  is  normal.

Changes  in  the  discharge  can  be  a sign  of  an  infection  if  the  discharge  is  gray,
green,  lumpy,  or  has  a bad  smell,  or  if  the  vagina  itches  or  burns  (see  Chapter  18).

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Chapter  6:  Common  body  changes  in  pregnancy

Difficulty  getting  up  and  down

It  is  better  if  a pregnant  woman  does  not  lie  flat  on  her  back.  When  a woman  is  on
her  back,  the  weight  of  the  womb  presses  on  the  big  blood  vessels  that  bring  food
and  oxygen  to  the  baby.  If  the  mother  wants  to  be  on  her  back,  she  should  put
something  behind  her  so  she  is  not  lying  completely  flat.

A pregnant  woman  should  also  be  careful  how  she  gets  up.  She  should  not
sit  up  like  this:

Getting  up  like  this  can  harm  the
muscles  of  the  belly.

NO!

Shortness  of  breath

Many  women  get  short  of  breath  (cannot  breathe  as  deeply  as  usual)  when  they  are
pregnant.  This  is  because  the  growing  baby  crowds  the  mother's  lungs  and  she  has
less  room  to  breathe.  Reassure  her  that  this  is  normal.

But  if  a woman  is  also  weak  and  tired,  or  if  she  is  short  of  breath  all  of  the  time,
she  should  be  checked  for  signs  of  sickness,  heart  problems,  anemia  (see  page  116),
or  poor  diet  (see  page  117).  Get  medical  advice  if  you  think  she  may  have  any  of
these  problems.

Feeling  hot  or  sweating  a lot

Feeling  hot  is  very  common,  and  as  long  as
there  are  no  other  warning  signs  (such  as  signs
of  bladder  infection,  see  page  128),  the  woman
should  not  worry.  She  can  dress  in  cool  clothes,
bathe  frequently,  and  drink  plenty  of  water
and  other  fluids.

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Body  changes  and  discomforts

The  mask  of  pregnancy

The  mask  of  pregnancy  is  a name  for  dark-colored
areas  that  may  appear  on  the  face,  breasts,  and  belly
of  some  pregnant  women.  This  mask  is  not  harmful.

Usually  most  of  the  color  goes  away  after  the  birth.

A woman  may  be  able  to  avoid  dark  areas  on  her
face  by  wearing  a hat  when  she  goes  out  in  the  sun.

Purple  spots  on  the  skin

Purple  spots  come  from  small  groups  of  veins  under  the
skin.  They  sometimes  happen  when  blood  vessels  swell.
They  are  not  harmful  and  usually  go  away  after  the  birth.

dark-

colored

areas

Aches  and  pains  in  the  joints

A pregnant  woman's  body  gets  soft  and  loose  so  the  baby  can  get  bigger,  and  so
she  can  give  birth.  Sometimes  her  joints  also  get  loose  and  uncomfortable,
especially  the  hips.  This  is  not  dangerous,  but  she  can  more  easily  sprain  her  ankles
or  other  joints.  So  she  should  move  more  carefully.  Her  joints  will  feel  better  after
the  birth.

Sudden  pain  in  the  side  of  the  lower  belly

The  womb  is  held  in  place  by  ligaments  on  each
side.  Ligaments  are  like  ropes  that  attach  the
womb  to  the  mother's  bones.

A sudden  movement  will  sometimes  cause  a
sharp  pain  in  these  ligaments.  This  is  not
dangerous.  The  pain  will  stop  in  a few  minutes.
It  may  help  to  stroke  the  belly  gently,  or  to  put
a warm  cloth  on  it.

the  womb

Cramps  in  early  pregnancy

It  is  normal  to  have  mild  cramps  (like  mild  monthly  bleeding  cramps)
at  times  during  the  first  3 months  of  pregnancy.  These  cramps  happen
because  the  womb  is  growing.

Cramps  that  are  regular  (come  and  go  in  a pattern)  or  constant
(always  there),  are  very  strong  or  painful,  or  come  with  spotting  or
bleeding  are  warning  signs.  The  woman  may  have  a tubal  pregnancy
(see  page  113)  or  maybe  having  a miscarriage  (see  page  91).  She
should  get  medical  help  immediately.

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Chapter  6:  Common  body  changes  in  pregnancy

Baby's  kicks  hurt  the  mother

Most  of  the  baby's  movements  feel  good.  But  sometimes  babies  kick  very  hard  or
always  in  the  same  place.  And  sometimes  the  baby's  head  bounces  against  the
mother's  back  or  bladder  during  the  last  weeks  of  pregnancy.  These  movements
may  make  the  mother  sore  or  uncomfortable,  but  they  are  not  harmful.

WARNING!  The  mother  usually  feels  regular  kicks  every  day  by
the  6th  or  7th  month.  If  the  baby  stops  kicking  for  a few  hours,
it  is  OK.  But  if  the  mother  feels  no  movement  for  more  than
a day  and  a night,  there  may  be  a problem.  The  mother
should  meet  with  her  midwife  or  get  medical  help.

Back  pain

Many  women  get  back  pain.  The  weight  of  the  baby,  the  womb,  and  the  waters
puts  a strain  on  the  woman's  bones  and  muscles.  Too  much  standing  in  one  place
or  leaning  forward  can  cause  back  pain.  Hard  work  can  also  cause  back  pain.

Most  kinds  of  back  pain  are  normal.  But  it  can  be  caused  by  a kidney  infection
(see  page  128).

Encourage  husbands,  children,  other  family  members,  or  friends  to  massage  the
woman's  back.  A warm  cloth  or  hot  water  bottle  on  her  back  may  also  feel  good.
Her  family  can  also  help  by  doing  some  of  the  heavy  work  (carrying  small
children,  washing  clothes,  farming,  and  milling  grain)  for  her.

A woman  can  also  do  an  exercise  — called  the  angry  cat  exercise  — to  reduce
lower  back  pain.  She  should  do  this  exercise  several  times  in  a row,  2 times  a day,
and  whenever  her  back  hurts  her.

Start  on  hands  and  knees  Push  the  lower  back  up.

with  the  back  flat.

Return  to  flat  back.
Repeat.

80

Point  the
toe  up,

then  stroke  Do
the  leg.  the

Leg  cramps

Many  women  get  foot  or  leg  cramps  —
sharp  sudden  pain  and  tightening  of  a
muscle.  These  cramps  especially  come
at  night,  or  when  women  stretch  and
point  their  toes.  To  stop  the  cramp:  flex
the  foot  (point  it  upward)  and  then
gently  stroke  the  leg  to  help  it  relax  (do  not

stroke  hard).  See  page  273  to  learn  when  leg  pain  can  be  dangerous.

not  point
toe  down.

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Body  changes  and  discomforts

To  prevent  more  cramps,  a woman  should  not  point
her  toes  (even  when  stretching),  and  she  should  eat
more  foods  high  in  calcium  and
potassium.  The  woman  can  also  try
taking  calcium,  magnesium,
and  potassium  pills.

Foods  rich  in  calcium  and  potassium
can  help  prevent  leg  cramps.

Headaches

Headaches  are  common  in  pregnancy  but  are  usually  harmless.  Headaches  may
stop  if  the  mother  rests  and  relaxes  more,  drinks  more  juice  or  water,  or  gently
massages  her  temples.  It  is  OK  for  a pregnant  woman  to  take  2 paracetamol  tablets
with  water  once  in  a while.

Some  women  have  migraine  headaches.  These  are  strong
headaches,  often  on  the  side  of  the  head.  The  woman  may  see  spots
and  feel  nauseated.  Bright  light  or  sunshine  can  make  them  worse.
Migraines  may  get  worse  in  pregnancy.

Unfortunately,  migraine  medicine  is  very  dangerous  in  pregnancy.  It  can  cause
labor  to  start  too  soon,  and  it  may  also  harm  the  baby.  It  is  better  for  a pregnant
woman  with  migraines  to  take  500  to  1000  milligrams  paracetamol,  and  rest  in  a
dark  room.  Although  coffee  and  black  tea  are  usually  not  healthy  in  pregnancy,
they  are  OK  occasionally  and  they  may  help  cure  a migraine.

Headaches  late  in  pregnancy  are  a warning  sign  of  pre-eclampsia,  especially
if  there  is  also  high  blood  pressure  or  swelling  of  the  face  or  hands.  See

page  125.

Other  pains

It  is  common  to  have  other  small  aches  and  pains  during  pregnancy.
Get  medical  advice  for  pain  that  is  not  normal  in  pregnancy,  such  as:
• red,  swollen  joints.

• severe  pain.

• signs  of  anemia  with  joint  pain  (see  page  1 16  on  anemia).

WARNING!  If  there  is  pain  in  one  leg  that  will  not  go  away,  it
may  be  a blood  clot.  See  page  273  and  get  medical  help.

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Chapter  6:  Common  body  changes  in  pregnancy

Changing  feelings  and  emotions

Pregnancy  is  an  important  time  in  a woman's  life.  Her  baby
is  growing  inside  her,  her  body  is  changing,  and  she  needs
more  food  and  more  rest.  As  a woman's  body  changes,
her  relationships,  her  sexuality,  and  her  work  life
can  change  too.

It s normal,  Alfredo,
she's  pregnant!
She  just  needs  you
to  listen  and  stay
close  to  her.

Maria!

What's  wrong  i
Can  I help?

( No . (sob)  I'm  fine.
I I don't  even  know
I why  I'm  crying.

Sudden  changes  in  feelings

Pregnancy  can  make  women  very  emotional
Some  women  laugh  or  cry  for  no
clear  reason.  Some  feel  depressed,
angry,  or  irritable.

Odd  laughing  or  crying  and
other  sudden  mood  changes  or  strong
feelings  are  normal.  They  usually  pass  quickly.

But  do  not  ignore  a woman's  feelings  simply
because  she  is  pregnant.  Her  feelings  are  real.

Worry  and  fear

Many  women  worry  when  they  are
pregnant,  especially  about  the  baby's  health

and  about  giving  birth.  A woman's  worries  about  other  problems  in  her  life
may  also  become  stronger  when  she  is  pregnant.

Such  worries  are  normal.  They  do  not  mean  that  something  bad  will  happen.
Women  with  these  feelings  need  emotional  support,  like  someone  to  listen  to  their
worries  and  encourage  them  to  feel  hopeful.  They  may  also  need  help  to  solve  the
problems  they  are  having  in  their  lives,  like  problems  with  their  partners,  money,
drugs  or  alcohol,  or  other  issues.

Strange  dreams  and  nightmares

Pregnant  women  may  have  strong,  vivid  dreams.

They  can  be  beautiful,  strange,  or  frightening.

For  many  people,  dreams  are  an  important  way  of
understanding  themselves  and  the  world.  Some  people
believe  that  dreams  can  tell  us  about  the  future  or  give
us  messages  from  spirits.

But  usually,  when  something  happens  in  a dream,
that  does  not  mean  that  it  will  happen  to  us  in  life.  The  events  in  the  dream  may
be  telling  us  what  we  are  afraid  of  or  what  we  desire.  Or  they  may  simply  be  stories
our  minds  make  up  while  we  sleep.  Women  who  are  having  frightening  dreams
may  need  someone  to  talk  to  about  their  hopes,  fears,  and  feelings.

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Changing  feelings  and  emotions

Forgetfulness

Some  women  forget  things  when  they  are  pregnant.  For  most
women,  this  is  not  a big  problem.  But  some  may  worry  if  they
do  not  know  it  is  normal.  No  one  knows  why  women  become
more  forgetful  when  they  are  pregnant,  but  it  is  common.

Feelings  about  sex

Some  women  do  not  want  much  sex  when
they  are  pregnant.  Others  want  sex  more
than  usual.  Both  feelings  are  normal.

Having  sex  and  not  having  sex  are  both  OK
for  the  woman  and  her  baby.  Sex  is  not
dangerous  for  the  baby.

Sometimes  sex  is  uncomfortable  in
pregnancy.  A woman  and  her  partner  can  try  different  positions  for  making  love.  It
may  feel  better  with  the  woman  on  top,  or  in  a sitting  or  standing  position,  or
with  the  woman  lying  on  her  side.

There  are  other  ways,  besides  sexual  intercourse,  for  couples  to  be  close  and  please
each  other.  Some  couples  touch  and  massage  each  others  bodies.  Some  talk  about
hopes  and  fears  together.

Safer  sex

When  a pregnant  woman  has  sex,  it  is  important
to  avoid  infection  by  making  sure  that  anything
put  inside  her  body  is  clean.  This  includes  the
penis  and  hands.

A man  who  is  having  sex  with  more  than
one  woman  must  always  use  condoms  —
including  with  his  pregnant  partner.

Condoms  are  a good  way  to  prevent  infections,
HIV,  and  other  illnesses.  See  Chapter  18  to
learn  more  about  HIV  and  other  sexually
transmitted  infections.

Sex  and  early  labor

A woman  who  has  gone
into  early  labor  in  other
pregnancies  might
choose  to  avoid  sex  after
the  6th  month.  This  may
help  prevent  going  into
labor  too  early.

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A Book  for  Midwives  (201  0)

pregnancy

Chapter  7

Learning  a pregnant  woman's  health  history

n this  chapter:

Questions  in  a pregnancy  health  history

Does  she  have  signs  of  pregnancy? ...  86

How  pregnant  is  she  now?

When  is  the  baby  due? 88

How  old  is  she? 90

How  many  children  has  she  had?  ....  90

Has  she  had  any  miscarriages  or
abortions? 91

Has  she  had  any  problems  with  past
pregnancies  or  births? 93

Is  she  healthy? 97

Malaria 98

HIV  and  AIDS 99

Has  she  been  vaccinated  against
tetanus?  If  yes,  when? 101

Is  she  taking  any  medicines  now?  ...  103

86

Has  any  medicine  ever  given  her
problems? 103

What  else  in  her  life  might  affect  her
pregnancy  and  birth? 104

Money 104

Living  conditions 104

Distance  from  care 104

Work 105

Family 105

Making  a transport  plan 106

84

1 **  l if  f Skit  or

www. nesperian.org

Learning  a pregnant
woman's  health  history

To  give  good  care  to  a pregnant  woman,  you  should  find  out  about  her  general
health,  her  past  health,  and  her  past  pregnancies  and  births.  You  also  need  to  know
what  this  pregnancy  has  been  like  so  far.  This  is  called  a health  history.

Learning  a woman's  health  history  will  help  you  give  advice  to  make  this
pregnancy  and  birth  as  safe  as  possible.

The  best  way  to  learn  about  a woman's  history  is  to  ask  her.  At  first,  she  may  not
be  comfortable  talking  with  you.  If  she  feels  shy  about  her  body  or  about  sex,  it  may
be  difficult  for  her  to  tell  you  things  that  you  need  to  know  about  her  health.  Try  to
help  her  feel  comfortable  by  listening  carefully,  answering  her  questions,  keeping
what  she  tells  you  private,  and  treating  her  with  respect.

This  chapter  suggests  questions  to  ask  each  woman  so  you  can  learn  more
about  her.  You  probably  have  some  questions  of  your  own  that  you  want  to  ask
but  that  we  do  not  include  here.  For  example,  if  there  is  hepatitis  B in  your
community,  you  may  want  to  ask  the  woman  if  she  has  hepatitis  B or  tell  her  how
to  prevent  it.  Think  about  the  information
you  need  to  know  in  order  to  give  f
good  care.  What  questions  do  you
usually  ask  a pregnant  woman?

If  you  can,  write  down  what  you
learn  about  each  pregnant  woman.

This  information  may  be  needed
later  in  the  pregnancy,  or  during
labor  or  birth.

After  learning  a woman's  health
history,  and  every  time  you  meet
with  a pregnant  woman,  you
should  do  a regular  pregnancy
checkup.  The  next  chapter  of  this
book,  Chapter  8,  explains  how  to
do  the  regular  pregnancy  checkup.

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85

Chapter  7:  Learning  a pregnant  woman's  health  history

Questions  in  a pregnancy  health  history
Does  she  have  signs  of  pregnancy?

Some  signs  of  pregnancy  are  sure  signs  — they  mean  the  woman  is  definitely
pregnant.  Some  signs  are  probable  signs,  meaning  the  woman  is  probably
pregnant,  but  the  sign  could  be  caused  by  something  else.

Probable  signs  of  pregnancy

The  woman's  monthly  bleeding  stops.  This  is  often  the  first  sign  of  pregnancy.
Other  possible  causes  of  this  sign  are  poor  nutrition,  emotional  troubles,  or
menopause  (change  of  life).

The  woman  has  nausea  or  wants  to  vomit.  Many  pregnant
women  have  nausea  in  the  morning  (which  is  why  this  feeling
is  often  called  "morning  sickness"),  but  some  women  may  feel
this  way  all  day.  Nausea  is  common  during  the  first  3 months
of  pregnancy.  Other  possible  causes  of  this  sign  are  illness  or
parasites.

The  woman  feels  tired  and  sleepy
during  the  day.  This  is  common  in  the
first  3 or  4 months  of  pregnancy.  Other
possible  causes  of  this  sign  are  anemia
(see  page  116),  poor  nutrition,
emotional  troubles,  or  too  much  work.

The  woman  needs  to  urinate  often.  This  is  most  common
during  the  first  3 months  and  the  last  1 or  2 months  of
pregnancy.  Other  possible  causes  of  this  sign  are  stress,
bladder  infection  (see  page  128),  or  diabetes
(blood  sugar  disease  — see  page  115).

The  woman's  belly  grows.  After  3 or  4 months,
the  pregnancy  is  usually  big  enough  to  be  seen  from
the  outside.  Other  possible  causes  of  this  sign  are  that  the
woman  has  a cancer  or  another  growth  in  her  belly
or  that  she  is  just  getting
…[truncated]

Summary: A Book  for  Midwives   Care  for  pregnancy,  birth,  and  women's  health    Susan  Klein,  Suellen  Miller,  and  Fiona  Thomson    Hesperian    Berkeley,  California,  USA    The  Hesperian  Foundation  and  the  contributors  to  A Book  for  Midwives  do  not  assume  liability  for  the  use  of  information  contained  in  this  book.   All  health  workers  have  a responsibility  to  be  honest  with  themselves  and  the  people  they  care  for  about  the  limits  of  their …