8-Days Traditional Birth Attendants (TBAs) Training workshop Report (Batch I)

Collaboration with:
PAKISTAN POVERTY ALLEVIATION FUND (PPAF)Under Supervision:
SALIK DEVELOPMENT FOUNDATION (SDF)
Title of Activity:
8-Days training workshop of TBAs (Traditional Birth attendants)
Duration of the Activity: 12 Feb. to 19 Feb., 2012 (08Days)
Venue of the Activity: Community Health center Komaila Kohistan
Resource Person: Miss Aliya (LHV), Miss Munaza (LHV)
Timings of the Training Workshop:  09:00 am to 05:00 pm  Introduction:
The training was conducted by the support of Salik development foundation and collaboration of Pakistan Poverty Alleviation Fund (PPAF). Core training generally focuses on teaching TBAs to perform deliveries in a more hygienic and safer fashion, discouraging harmful practices, recognizing danger signs and referring women with complications to facilities where essential obstetric care is available. Training comprised of 8 days module in whish start was taken with the recitation of Quran Pak, participant introduction, and then TBA training modules were disused with exercise and practical demonstration on daily basis for 8 days. In this training workshop TBAs are able to learn
•    Female reproductive system
•    Pregnancy and pregnancy sign and symptoms
•    Prenatal and postnatal checkups
•    Exemplary TBA
•    Advices pregnant women
•    Danger sign of pregnancy
•    Prompt action for referral mechanism
•    Preparation for delivery
•    Hygiene practices
•    Use of delivery kit
•    Labor pain
•    Delivery steps
•    Complication during three steps of delivery
•    3 delay model
•    Family planning
•    Communication between TBA and community health center
•    Newborn care
•    Breast feeding
•    Newborn vaccination
•    Infection of newborns children
•    Diarrheal diseases of children.

Objective of the Training:
A) General Objectives
To contribute to the prevention of maternal-infant morbidity and mortality by training TBAs in skills for managing obstetrical and neonatal emergencies in order to save Lives in their communities.

B) Specific Objectives:
To provide training so that TBAs can effectively:
•    Assist clean deliveries (without risk of infection), including safe
delivery of the Placenta
•    Evaluate pregnant women; detect danger signs before, during, and
following Childbirth; and provide timely referral
•    Use the information and referral system properly
•    Give first aid in obstetrical and neonatal emergencies in the community
•    Provide immediate care to the normal newborn and apply infant first aid
should a Complication occur

Detailed list of Participants:

S.No Name Husband Name Present Duty station
1 Guftar Bibi Subhan ud din RHC Dassu
2 Gafora Bibi Sultan Muhammad BHU Jalkot
3 Rameel Zari Muhammad Ali BHU Kolai
4 Kefayat Bibi Sada Gul BHU Sharakot
5 Arfeen Bibi Muhammad Irfan CHC Komaila
6 Noor Jehan Usman Gani RHC Ronila
7 Noor Jehan Shar Muhammad RHC Patten
8 Samyat Bibi Subhan ud din BHU Keyal
9 Begam Jan Muhammad Ayaz CHC Komaila
10 Reema Muhammad Ali BHU Baryai
 Teaching Aid Used:
Charts, stationery, flip cards Markers, White Board, placenta model, child birth model, dollsMethodology of the Workshop:
Pre test ,post test Question/ answer sessions, Group Work exercise, discussions and practical demonstration , Lectures, role play, Training notes distribution among trainees.
Opening of training session (12-02-2012):
Training was started with the Recitation of Some versus from the Holly Quran. After recitation, introduction session was executed by the Master Trainer in an interesting way. In which the trainer made groups of participants who introduced the other member in their group.  It was the best way of among participants that help them all introduction to know about each other
in a short  time as well as help them
Presence of Dr Gul Bharg (EDO Health) in opening ceremony of TBAs training workshop
out to build rapport. Then EDO health Arrived and gave the opening remarks and appreciate the SDF and PPAF support and also pray for the success completion of the training.

1st Day training contents topics (12-02-2012):

S.No topics contents Methodology /techniques
1 introduction Opening session

Participant and trainer introduction

Smart organizational introduction

 

Group exercise
2 Role of TBA Role of TBA in present and in future Group discussion
3 Pretest Pretest of mother and newborn care Individual participation
4 Principals Principal and norms of training Group discussion
1 Reproductive system Female reproductive system

Name and function of female reproductive system

Brain storming

Lecture

Discussion

Use of model for showing organs

Use of flicks charts

2 Menstruation cycle Menarche

menopause

discussion
3 Pregnancy Identifies pregnancy

Natural growth and care of baby

Brain storming

Lecture

Discussion

Use of model

Use of charts

 

4  Pregnancy diagnosis Sign ad symptoms of pregnancy

Possible and certain sign of pregnancy

Brain storming

Lecture

Discussion

Use of charts

Role play

 

5 Prenatal checkups Importance

Schedule

Methods of prenatal checkups

Full body checkup

Abdominal checkup

 

6 Practice Prenatal checkup Practical demonstration one by one participants
After introduction session ground rules of training was discussed by the candidates that can be either barriers in learning or that can help to learn more with full and keen attention. Pre- test was given to the participants to rate their understanding about the objectives and knowledge. Trainer threw light on the objectives of the training which is crystal understanding of prevention of infant mortality and morbidity by training TBAs in skills for managing obstetric and neonatal emergencies in order to saves live in their communities.

Trainer disused the female reproductive system by brain storming, lecture, by using model of organs and charts .Discussion was carried out on identifies pregnancy ,sign and symptoms of pregnancy ,normal progress of pregnancy and well being of unborn baby  by appropriately performing the following techniques in prenatal checkups like.
•    Palpitation of the abdomen
•    Assessment of fundal height
•    Auscultation of fetal heart tone
•    By measuring of abdominal girth

Focus was given on prenatal checkups as they are very important for the pregnant women to know the position and growth of fetus. At the end practical performance was done by each participant.

 Picture Views of group work
trainer teaching the TBAs by using model
2nd Day training contents topics (13-02-2012):

S.No topics contents Methodology /techniques
1 Exemplary TBA Strengths of TBA Group exercise

Group discussion

 

1 Advises for pregnant women Personal hygiene

Care for breasts

Nutritional needs

Rest and exercise

Clothing and shoeing

Tetanus vaccination

Brain storming

Lecture

Discussion

Practical demonstration

Role play and discussion

2 Precautionary advices for pregnant women Use of medicines

Drugs addiction or use of drugs

X-rays

Traveling

Brain storming

Lecture

Discussion

Practical demonstration

Role play and discussion

Use of charts

 

3 Common discomforts of pregnancy and advices for that Nausea /vomiting

Morning sickness

Constipation/ hemorrhoids

Varicose veins of legs and vulva

Vaginal discharge

Itching of the skin in vulva area

Cramps of the legs

Inguinal pain

Urinary frequency and in continence of urine

Brain storming

Lecture

Use of charts

Discussion

Role play and discussion

4 Danger sign /severe discomforts of pregnancy

Identifies patient at risks

Immediate action/arrangement or emergency care

Referral

Severe anemia

Start of bleeding

Excessive vomiting

Cession of fetal growth

Excessive swelling of legs

Tenderness

Sharps abdominal pain

High blood pressure and eclamsia

Brain storming

Lecture

Use of charts

Discussion

Role play and discussion

5 Pregnancy with risks of complications/client at risk

 

Identification of  client at risks and immediate ,suitable  in time referral Brain storming

Lecture

Use of charts

Discussion

Role play and discussion

6 Practice Review of session

Examination of pregnant women

Role play

Practical demonstration

discussion

Session of 2nd day started with the name of ALLAH. After then review & comments of previous lectures and topics were taken from the participants. It was a good to refresh previous topics and to develop link of that topics with new topics that can be discussed in the current day. For the interest of participant’s and refreshing their mod topic of exemplary TBA was brought to workshop forum, every participant have gave there comment and disused the strengths of TBA that TBA should have the knowledge of proper skills and safe practices in the community and have decision power for the referral of the expectant women at risk to the health service.
According to agenda one by one topics were taught with complete understand tools .The above mention topics were important and TBA should have excellent understanding skills .Trainer discussed nutritional significance during pregnancy .she emphasized on breast care like
•    Cleanliness
•    Breast enlargement
•    Pigmentation
•    Nipples care

Trainer draws the attention of participant TBAs on personal hygiene like clothing, shoeing, and bathing of expectant client.
What types of medicines should given or not given in pregnancy were discussed also the harmful effects of use of drugs for both mother and fetus were explain .Session was continue with the topics of common discomforts during pregnancy and possible advices for pregnant women were discussed in groups and asked to the participant to write on the charts according to their knowledge and experience.
After that very important and considerable topic was discussed, they include that how TBA identifies and manage the client at risk including the knowledge of:
•    Bleeding from the vagina in the first few months of pregnancy
•    Bleeding from the vagina in the last few months of pregnancy
•    Excessive vomiting
•    Excessive weakness
•    Excessive swelling of legs alone and combine with headache and epigastric pains and or convulsions
•    High blood pressure eclamsia
•    Sharps abdominal pains
•    Disappearance of fetal movement
How to identifies expectant women danger sign and symptoms of complication and also give emergency care in this situation while awaiting professional assistance was also disused with example and experience of the trainer and TBAs. Refer and accompanies client to the clinic or health service if professional assistance is not immediately available was also demonstrated. End of session done on practice and role play for the more understanding of participants.

Group work and practical demonstration

3rd Day training contents topics (14-02-2012):

S.No topics contents Methodology /techniques
1 Review of previous day ·          Summary of the previous day    Group exercise
Group discussion
1 Preparation for delivery ·           Mother

·          Midwife/TBA

·          Instruments

·          Place

 

·          Brain storming

·          Lecture

·          Discussion

 

2 Clean delivery ·          Clean/ hygiene practices for delivery

·          Mother

·          Midwife/TBA

·          Instruments

·          Specific method of hand washing of midwife/TBA

 

 

·          Brain storming

·          Lecture

·          Discussion

 

3 Use of sterilized delivery kit ·          Sterilized delivery kit

·          Advantages

·          Items in delivery kit(things)

·          Instructions for use

·          Discards of used things

·          Brain storming

·          Lecture

·          Discussion

 

4 True and false labor pain ·          Difference between true and false labor pain

·          Correction of harmful practices during false labor pain

 

·          Briefing

·          Discussion

 

5 Stages of delivery First stage of delivery

·          True sign and symptoms of delivery

·          Proper arrangements

·          Correction of harmful practices

·          Brain storming

·          Lecture

·          Use of charts

·          Discussion

·          Role play and discussion

2nd stage of delivery

·          Sign and symptoms of 2nd stage of delivery

·          Proper positioning of pregnant women

·          Practical demonstration of delivery  and care of new born on dummy

·          Correction of harmful practices

·          Use of charts

·          Discussion

·          Practical demonstration on child birth model(dummy)

3rd  stage of delivery

·           Sign of Separation of placenta from uterus

·          Delivery of placenta/expulsion of placenta

·          Examination of placenta

·          Correction of harmful practices

·          Briefing

·          Use of charts

·          Discussion

·          Practical demonstration on child birth model(dummy

3rd  day of training was started with the Holly Name Of ALLAH and after recitation trainer got feedback from the participants about previous training session all participants were equally interested to present  review, next topic discussed by trainer was that what are the step should follow by the midwife during delivery ,3 stages of delivery were discussed and these are very important for consideration .Trainer explain the appropriate preparing of mother for delivery, birth site and of material  supplies and equipment ,trainer demonstrated the techniques of boiling and sterilizing the instrument and use of delivery kits and discard of used items.
Differentiation between true and false labor pain was discussed by the involvement of TBA experience and also trainer briefly discussed that avoid the harmful practices during these stages .She told give concentration on the positioning of mother and also she explained the procedure of delivery and care of new born baby on dummy (child birth model).
Outstanding technical session was given on identifying the sign of separation of placenta from the uterus, uses the safe techniques for delivery of placenta and its examination. All the session was made fruitful by using the methodologies of learning like
•    Briefing
•    Discussion
•    Practical demonstration on models
•    Use of charts and broachers
•    Group discussion

As usual end of session was took place on discussion question answer session and one by one practical performance.
Participants performing practically hand washing methods
4th   Day training contents topics (15-02-2012):

S.No topics contents Methodology /techniques
·    Review of previous day

·    Good society

 

·    Summary of the previous day

·    Factor effecting good society and role of TBA in society

·          Group exercise

·          Group discussion

 

1 Complications during three stages of delivery and referral Complication of 1ststage

·          Identification

·          Basic arrangements

·          Refer to proper place(health service)

·          Brain storming

·          Lecture

·          Discussion

·          Use of charts

 

Complication of 2ndstage

·          Identification

·          Basic arrangements

·          Refer to proper place(health service

·          Brain storming

·          Lecture

·          Discussion

·          Use of charts

 

Complication of 3rdstage

·          Identification

·          Basic arrangements

·          Refer to proper place(health service

·          Brain storming

·          Lecture

·          Discussion

·          Use of charts

 

2 Three delay model ·          Practical performance of TBA on three delay model

·          Role of TBA in managing delays at home and community

·          Briefing

·          Negative role play and discussion

·          Positive role play and discussion

3 Intra uterine contraceptive device(multilod and copper T) ·          Introduction

·          Importance of mother and child examination

·          Schedule

·          Method of examination

·          Role of TBA/midwife

·          Brain storming

·          Lecture

·          Discussion

·          Use of charts

 

4 Examination in intra uterine contraceptive device Method of examination of mother

·          Advice for mother

·          Mother nutrition

·          Mother milk and colostrums

·          Cleanness

·          Rest

·          Exercise

·          Urine and stool

·          Child vaccination

·          Complementary feeding of child

·          Family planning

·          Brain storming

·          Lecture

·          Discussion

·          Role play and discussion

5 Common problems of intra uterine contraceptive device and its solution ·           Common Abdominal cramps

·          Constipation

·          Fullness of breast

·          Treatment

 

·          Brain storming

·          Lecture

·          Discussion

·          Role play and discussion

6 Practice ·          Practice of delivery on dummy ·          Practical demonstration on dummy (model)
4th Day of training session was start with the name of ALLAH. After then review & comments of previous lectures and topics were taken from the participants. Trainer discussed the above mention topic and content by using the methodologies of teaching /delivering the training. In this technical session TBAs able to learned the identification of complication occur during three stages of delivery ,what basis arrangements should  do and knowledge of proper refer at proper health service .focus was given on institute immediate care and appropriately manage the following unexpected conditions until physician or midwife arrive .in such condition
•    Prolonged labor
•    Bleeding before baby born
•    Convulsion during labor
•    Breech presentation
•    Shoulder presentation
•    Prolapsed of cord

Referral of patient to the proper health service in community is very important for the survival of both mother and inborn child.
Three delay models on the mother and inborn child death was completely discussed in groups’ presentation during session. Role of TBA/midwife in the management of delays at home and in community was described in effective way, after that trainer describe the intra uterine contraceptive device use and examination of mother and list out the advices for mother regarding nutrition, mother milk, rest, exercise .child vaccination and complementary feeding .brief discussion was also done on problem and solution of intra uterine contraceptive device.
At the end same routine was follow i.e. practical performance and practice of each participant
Practical performance by participants
5th   Day training contents topics (16-02-2012):

S.No topics contents Methodology /techniques
1 Review of previous day Summary of the previous day

 

Group exercise

discussion

 

Gender Role of TBA in Gender discrimination Group exercise

discussion

1 Complications in use of intra uterine contraceptive device and referral In time Identifies complication and arrangement

Excessive bleeding

Infection

shocks

Sepsis of breasts

Swelling of veins

Cut during delivery

Correction of harmful practices during complication

Referral protocols

Brain storming

Lecture

Discussion

Use of charts

Practical demonstration

 

2 Family planning Role of TBA

Advantages of adopting family planning

Disadvantages of not adopting family planning methods

Contraceptive methods

Cultural

Temporary

permanent

 

Brain storming

Lecture

Discussion

Use of charts

Practical demonstration

Role play and discussion

 

3 Improvement in coordination between TBA and nearby Health facility Communication between TBA and Health staff of nearby facility

Taking information about the provision of facilities in health centers.

General discussion
As usual session was started with the Pak name of ALLAH .After recitation of some verses of Holy Quran review of previous session was taken by the master Trainers .For the attention and interest of participants general discussion on gender discrimination was carried out .above mention topics was disused with teaching aids to make the session more effective fruitful .one by one problems of intra uterine device was described by trainer like excessive bleeding, infection due to IUCD and other problems were discussed properly through practical examination and  discussion .  Focusing points was referring of patient in complication to the health service area.
Brief discussion of trainer and participants was made on family planning and contraceptive method for pregnancy spacing (cultural, temporary, permanent) .General discussion on coordination and communication of TBA with health staff and facilities was done that clear the mind and confusion of participants’ that how they communicate the health staff.
Trainer was teaching the method of using contraceptive
6th   Day training contents topics (17-02-2012):

S.No topics contents Methodology /techniques
1 Review of previous session

 

 

Review of previous session One by one question answer session

 

1 Care of newborn Drying the newborn

Warming of infant

Cleaning of mouth

Bathing the child

Brain storming

Lecture

Discussion

Use of charts

 

2 Management for the survival of newborn Use of gauze piece

Use of bulb sucker

Mouth to mouth breathing

Referral protocol

Brain storming

Lecture

Discussion

Practical demonstration on doll

Practice by participants

Use of charts

 

3 Newborn examination Importance

Schedule

Methods

Referral protocol

Brain storming

Lecture

Discussion

Practical demonstration on doll

Practice by participants

Use of charts

 

4 Breast feeding/mother milk Prelactial feed

Importance of colostrums

Importance of breast feeding

Procedure/ methods of breast feeding

Nutrition, rest ,and cleanness of lactating mother

Brain storming

Lecture

Discussion

Practical demonstration on doll

Practice by participants

Use of charts

Role play and discussion

Session was start with the name of ALLAH .After recitation review of previous session was taken this is very effected method of involvement of participants in order to judge the capacity and learning of the participants .Trainer discussed the topics in very technical methods .she describe how to dry the newborn and removing the all dried material in contact with the infant .she also told that wrap the newborn in pre warm cloth or blanket. Every candidate practically perform to maintain of the air passage clear, wipes excess mucus and water from the baby face. It was also demonstrate mouth to mouth berating, use of bulb sucker or gauze piece for the survival of and newborn.
Brief discussion was done on prelactial feed and importance of breast feeding and colostrums .Positioning and attachment method of breast feeding were discussed by showing flicks charts. For more perfection in activities practice was done on dummy at the end.
Trainer is showing practically that how to clear the mouth of newborn
7th   Day training contents topics (18-02-2012):

S.No topics contents Methodology /techniques
1 Review of previous session

 

 

Review of previous session One by one question answer session

 

2 communication definition

channels

factors

types and principals

Brain storming

Briefing

Discussion

Role play and discussion

Exercise

 

1 Breast feeding problem Problem of lactating mother

Problem of breast feed child

No breast feeding

Lack of breast feed for child

Brain storming

Lecture

Discussion

Use of charts

 

2 Complementary feeding /weaning  of child Importance

Types of balance diet

Time of initiation of complementary feeding

What should offer a child in complementary feed

Brain storming

Lecture

Discussion

Role play and discussion

3 Vaccination for newborn Importance

Schedule

 

Brain storming

Lecture

Discussion

Briefing

4 Problems of low birth weight and premature infants Problems of low birth weight and premature infants

Special care of infant

Specific growth

Warming and feeding

Danger sign

Diagnosis /identifies and immediate referral in emergencies

Brain storming

Lecture

Discussion

Practical demonstration on doll

 

5 Common problems of newborn Crying

Common jaundice

 

Brain storming

Discussion

Use of charts

6 Severe problems of newborn Sever jaundice

Convulsions

Bleeding problem in child

Brain storming

Discussion

lecture

7 Infection in children sources  of infection

diagnosis

prompt action/arrangements

referral

Brain storming

Discussion

lecture

8 Dangerous diseases of infant pneumonia

meningitis

tetanus

hepatitis B

 

Brain storming

Discussion

lecture

2nd last day session was again started with the name of ALLAH few verses from the holy Quran were recite by one of the participant. Session was taken again by the review and feed back of the participants because this suggestion was taken from them that review is very important and they said we can easily memorize the topic by this method.
By following the same routine and methodology above mention contents in the table were discussed by the master trainer in very effective and interesting manner so that participants involve their selves in the training with full concentration and participation. The purpose of this session was to make the TBA more competent and get aware of the skills and knowledge so that they can give appropriate information and instruction to the mother /family on infant care, diet of child from birth to 12 month ,complementary feeding ,what food should offer and it can be prepared.
Trainer disused with TBAs you should convince and disused with mother/family for newborn immunization and immunization schedule during home visits in communities .trainer also describe the some common and severe problems of infant and asked them for prompt action/arrangements for referral in case of emergency.
Trainer & participant demonstrated the position and attachment of baby for breastfeeding
8th   Day training contents topics (19-02-2012):

S.No topics contents Methodology /techniques
1 Review of previous day Summary of the previous day One by one question answer
2 Power/authority Exercise

Sources of power

Kinds

Positive use of power

Briefing

Group work

Discussion

Role play and discussion

1 Diarrheal disease in children Causes

Sign and symptoms

Control measure

treatment

Brain storming

Lecture

Discussion

ORS preparation method

Practice from TBAs

Use of charts

 

1 Review of full training review Group work

Discussion

2 Post test Comparison  of information of TBAs before and after the training Filling of forms after asking from the participant
3 End of training Closing remarks

 

Participants

Trainers

EDO health

4 Game Preparing  net of thread
5 Closing /ending ceremony of training Distribution of delivery activity

Distribution of certificates

Distribution of honoraria

Trainers

EDO health Kohistan

This was the last day of training began with the name of ALLAH ,after the recitation of some verses from Holy Quran review of the second last session was taken from participants. For the interest of TBAs general topic on the power/authority was discussed and how we use the power positively.
Last topic was disused with the participants by the trainer was diarrheal disease of children .which have major contribution in infant mortality. Causes of diarrhea in children were briefly disused precautionary measure and the treatment was highly focused by trainer .preparation method of ORS at homes was explain to the TBAs. One by one each participant practically had done this.
Post test was conducted at the end of technical session for the judgment the status of TBA that how much TBAs learned from this training. For this forms were filed from the TBAs. An interesting game was played by the participants in order to refresh the moods and environment of training set up, after that an oath was taken from the TBAs that they will act upon what they learn and also avoid the wrong practices which are done before.
Ending /closing Ceremony:
Concluding Session:
Training was concluded by the EDO health Kohistan Dr Gul Berg, Master Trainers Miss Aliya and Miss Munaza have reflected their precious remarks about training and objectives of TBA training and current project, They presented regards and bundles of thanks to Miss Aliya and Miss Munaza   for delivering such a benefited and knowledgeable training and gave her precious time to trained all the participants. Dr Gul Berg paid gratitude to the efforts and Support of Salik Development Foundation and PPAF. All participants were also very thankful to the trainers to share their knowledge with us .Participants documents there remarks for training and Salik development Foundation. Trainer also paid her compliments to all team members and President SDF and PPAF. Dr Gul Berg distributed certificates and honoraria to all the participants. Overall it was a good and healthy effort to enhance the existing knowledge and for further progress in learning point of view.
Dr. Gul Bharg (EDO Health (Kohistan) and Dr Hafiz-ul-Wahab (field supervisor) Distributing Certificates among the trainees.
Suggestions and feed back:
•    EDO Health and trainees suggest that such type of training should be conducted at least 1 time in a quarter or year.
•    Feedback from trainees were really appreciating they showed and proved their interest in learning and response positively.
•    EDO health also Show great interest in this training and gave positive response.Issues /challenges:
•    This training is itself a challenge because this was the first TBAs training in the history of Kohistan and its success was really a challenge
•    Accommodation for TBA was an issue because Kohistan is restricted area in cultural constraints so there should be safe place for them.
•    Weather of the Kohistan is also challenging.
•    Women of the community were restricted to go outside of their residency

Achievements against challenges:
•    By the blessing of ALLAH Salik development foundation succeeds in conducting the training in Kohistan with collaboration of PPAF and it is completed effectively.
•    Accommodation issue was solved by the coordination of welfare department
•    SDF support a lot for provision of basis need items to overcome the problems
•    People trust is going to build on the SDF in sense of their great efforts and activities for the Kohistan communities so in this basis TBAs are interested to attend the training.