Health promotion refers to any activity that aims to achieve better health in a community or a country. It includes the health education of individuals to enable them to control and change their lifestyles so that their health is improved. This is the main focus of this study session, in the context of your role as a health educator of pregnant women during antenatal care visits. But as you know from Study Session 2 of this Module, health promotion activities go far beyond this focus on individual behaviour, and include a wide range of social and environmental interventions that increase health and wellbeing in populations as well as individuals. Health promotion also includes disease prevention — actions taken to prevent a disease from developing, and health screening — the routine testing of individuals to see if they are at risk of developing a health problem. The relationship between health promotion, health education, disease prevention and health screening is represented in Figure 2.1 in Study Session 2.
Antenatal care (FANC, Study Session 13) provides a key entry point for a broad range of health promotion and disease prevention services. It is essential for healthcare providers and women to talk about important issues affecting the woman’s health and her pregnancy.
During the antenatal period, you can promote the health of the women in your care and the health of their babies before and after birth, by educating mothers about the benefits of good nutrition, adequate rest, good hygiene, family planning and exclusive breastfeeding, and immunization and other disease prevention measures. Your aim is to develop women’s knowledge of these issues so they can make better informed decisions affecting their pregnancy outcome — but you should never lose sight of the difficulties some women will face in being able to improve their lifestyles.
When you have studied this session you should be able to:
14.1 Define and use correctly all of the key words printed in bold. (SAQs 14.2 and 14.4)
14.2 Describe the major dietary constituents for good health in a pregnant woman, advise women on eating well with little money, and explain the problems resulting from a poor diet. (SAQs 14.1 and 14.2)
14.3 Explain the benefits of good hygiene and other self-care activities in pregnancy. (SAQ 14.3)
14.4 Explain the benefits of immunization against tetanus. (SAQs 14.3)
14.5 Explain the benefits of early and exclusive breastfeeding for the mother and for her baby. (SAQs 14.3 and 14.4)
14.6 Explain the benefits of family planning to achieve birth spacing and discuss postpartum contraception with pregnant women. (SAQ 14.4)
In this section (the biggest in this study session) we describe the nutritional requirements in pregnancy in detail and explain how you can advise women about eating well, even if they have very little money for additional food.
Eating well means eating a variety of healthy foods and also eating enough food. This combination helps a pregnant woman and her baby stay healthy and strong because it:
It is important for pregnant women (like everyone else) to eat different kinds of food (see Figure 14.1): main foods (carbohydrates), grow foods (proteins), glow foods (vitamins and minerals), and go foods (fats, oils and sugar), along with plenty of fluids. We will describe each of these food groups in more detail later in the study session.
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. They need to increase their usual food intake by at least 200 calories per day, or even more than this if they were underweight before they became pregnant. There are many ways to increase daily food intake by this amount: for example, one more serving of maize porridge and 12 groundnuts a day would meet this additional requirement.
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 injera or rice can be easier for these women to eat. For women who suffer from nausea, encourage small and frequent meals.
Poor nutrition can cause tiredness, weakness, difficulty in 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 the birth.
When you see pregnant women for antenatal care, or at village meetings and celebrations, in the market, try to find ways to enquire sensitively about the food they eat. The earlier pregnant 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, ask her: ‘What did you eat yesterday?’ Be sure to tell her what is healthy about what she eats, reinforce the positive efforts she is making to eat well. Then, if it is appropriate, make a suggestion for how she could eat better.
Remember that education about food is not enough on its own to change eating behaviour. 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. Some women may simply not like the taste of some healthy foods. To help a woman eat better, suggest healthy foods that she can afford and will choose to eat.
The biggest cause of poor nutrition is poverty. A very poor family can eat better by spending money wisely and not wasting what little they have. A father who buys alcohol, tobacco and ‘chat’ (or khat) 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.
Beans, peas and lentils belong to a family of vegetables called legumes. All 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. Planting legumes makes soil richer. Other crops such as maize will grow better in a field where legumes once grew (Figure 14.2).
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 — especially for a family that fishes or raises their own chickens. Eggs have a lot of protein, iron, and vitamin A. Eggs give more protein for less money than almost any other food.
Grains like teff, wheat, rice and corn are more nutritious when they have not been refined (processed to take out the colour). Taking out the colour takes out healthy things too. White bread and white rice have fewer vitamins, minerals and proteins than brown bread or brown rice. Dark teff and brown injera are more nutritious than the light-coloured ones.
When vegetables are boiled or steamed, some of the vitamins from the foods go into the cooking water. Use this water to make soups.
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.
Breast milk costs nothing, and has all the nutrition a baby or young child needs. Young children who are on exclusive breastfeeding do not need fortified milks or other foods until after the age of 6 months.
In most parts of the world, people eat one main food at each meal. This main food may be injera, rice, maize, wheat, millet, cassava, plantain, kocho, bulla, godere, shenkora, gishta, breadfruit or another low-cost, starchy food which is rich in carbohydrates. These foods give the body energy. But to grow and stay healthy, the body needs other types of food too.
Meat, fish and cheese are nutritious foods but they can carry parasites or disease when they are eaten raw. Pregnant women should eat fish, meat or cheese only when it is well cooked or pasteurised.
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 that are high in proteins are:
Go foods contain sugars and fats, which give the body energy. Everyone needs these foods to be healthy. Some healthy go foods that are high in sugars are:
Some ‘go foods’ that are high in fats are:
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 and fatty foods are expensive and not as healthy as fresh products. They also damage the teeth. It is better to eat go foods that are natural, not packaged.
Glow foods contain vitamins and minerals, which help the body fight infection and keep the eyes, skin and bones healthy and strong. Vitamins and minerals are known as micronutrients because they are very small. Fruits and vegetables are high in vitamins and minerals. It is important for pregnant women to eat as many different fruits and vegetables as they can. In the next section, we discuss the five most important vitamins and minerals that pregnant and breastfeeding women should eat every day.
Pregnant and breastfeeding women need more of these five vitamins and minerals than other people do — iron, folic acid, calcium, iodine and vitamin A. They should try to get these vitamins and minerals every day.
Why do you think that a pregnant woman needs more of these vitamins and minerals?
The baby needs them to grow and be healthy and to prevent birth defects. A pregnant woman needs them to have enough energy to look after herself and her family, to fight infections and to keep her strong for completing the pregnancy, giving birth safely and breastfeeding the baby afterwards.
Iron helps make blood healthy and prevents anaemia (you will learn about diagnosing and treating anaemia in Study Session 18 of this Module). 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. It is also important in the production of good breast milk.
These foods contain a lot of iron (Figure 14.3):
It can be difficult for a pregnant woman to get enough iron, even if she eats iron-rich foods every day. She should also take iron pills (or liquid iron drops) to prevent anaemia. These medicines may be called ferrous sulfate, ferrous gluconate, ferrous fumerate or other names (ferrous comes from the Latin word for iron).
Iron pills or drops can be obtained from pharmacies and health institutions, but throughout Ethiopia you will give iron pills routinely to pregnant women as part of focused antenatal care. She should receive 300 to 325 mg (milligrams) of ferrous sulphate once a day taken by mouth, preferably with a meal. This dosage is usually supplied in a single tablet combined with folate (see below).
The iron pills may cause nausea, make it hard for the woman to pass stool (constipation), and her stool may turn black, but it is important for the woman to keep taking the iron pills because anaemia can cause complications during pregnancy, during delivery, and after the baby is born. It is helpful for the woman to take the iron pill with a meal, drink plenty of fluids, and eat plenty of fruits and vegetables to avoid nausea and constipation. The black colour of the stool is a normal side-effect from the iron and is not harmful.
Lack of folate can cause anaemia in the mother and severe birth defects in the baby. To prevent these problems, it is important if possible for a woman to get enough folic acid in her diet before she becomes pregnant and she should certainly do this in the first few months of pregnancy.
Foods rich in folate that pregnant and breastfeeding women should try to eat every day (Figure 14.4) include:
As well as eating as many of these foods as she can, all pregnant women should also take 400 mcg (micrograms) of folic acid tablets orally every day during pregnancy. She should be able to get these tablets from you as part of Focused Antenatal Care.
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. These foods (Figure 14.5) contain a lot of calcium:
Women can also get more calcium in these ways:
Iodine prevents goitre (swelling of the neck) and other problems in adults. Lack of iodine in a pregnant woman can cause her child to have cretinism, a disability that affects thinking and physical features.
The easiest way to get enough iodine is to use iodized salt instead of regular salt (Figure 14.6). It is available in packet form labelled ‘Iodized salt’ in many market places.
Vitamin A prevents poor vision at night or when light intensity is low and helps to fight infections. Lack of vitamin A also causes blindness in children. A woman needs to eat plenty of vitamin A-rich food during pregnancy and while breastfeeding.
Dark yellow and green leafy vegetables and yellow fruits contain lots of vitamin A. Name some of these vegetables and fruits.
Carrots, mangoes, spinach, cabbage. (You may have suggested other good examples.)
Other sources of vitamin A are liver, fish liver oil, milk, eggs and butter.
Along with eating healthy foods, women should drink plenty of clean water and other healthy fluids every day. Fruit juices, animal milks and many herbal teas are all healthy fluids to drink.
During pregnancy, women should be especially careful about personal hygiene. Pregnant women sweat more and have more vaginal discharge than non-pregnant women (due to hormonal changes), and they may be more vulnerable to infection by germs in the environment. Keeping the body clean helps prevent infection. Hand washing with soap is the most important hygiene action she can take, especially before preparing food and after going to the toilet. If possible, a pregnant woman should wash her body every day with clean water — especially her genital area.
Dental hygiene is especially important during pregnancy because increased oestrogen levels can cause swelling and increased sensitivity in gum tissues. Whether she cleans her teeth with a dental stick or a toothbrush and toothpaste, the pregnant woman should do so regularly.
As well as eating well and keeping clean, pregnant women need to get enough sleep and rest every day. This will help her to avoid developing high blood pressure (discussed in detail in Study Session 19 later in this Module), and oedema (swelling of the feet and ankles due to fluid collecting in the tissues). Good rest also helps her to stay strong and gives the fetus a better chance of being born healthy.
Many women have to work throughout their pregnancy in the fileds, factories or shops, as well as in their own homes. This can be especially hard for women during pregnancy, because they get more tired than usual — especially in the last few weeks. Explain to them and their families that the woman should try to rest for a few minutes every 1 to 2 hours (Figure 14.7). This will also help her to enjoy her pregnancy.
Make sure that women know that whatever they put into their body will pass across the placenta and into the baby (Figure 14.8). Cigarette smoke, alcohol and illegal drugs such as opium, heroin, cocaine and barbiturates are dangerous for anyone, but especially harmful to the developing fetus. Even one or two alcoholic drinks a day during pregnancy can result in the baby being born too small, or with birth defects or disabilities that affect the brain.
She should also be advised to avoid:
Tetanus is a very serious, life-threatening infection, which damages the nervous system and is caused by bacteria in the environment, for example in soil. Tetanus toxoid immunization is the best protection against tetanus for the woman and her baby. Therefore, it is very important for her to be immunized according to the schedule on her card, and to bring her card to every antenatal care visit (Figure 14.10).
In the Module on Postnatal Care, you will learn that to prevent tetanus in the newborn, the stump of the baby’s umbilical cord should be kept clean and dry after birth and until it falls off. This is one reason why it is so important for the woman and her family to plan and prepare for a clean and safe childbirth attended by a skilled health provider such as you.
Breastfeeding positions and good attachment of the baby are described in detail in the Postnatal Care Module, but you should lay the foundations during your antenatal care visits with pregnant women — especially those having their first baby. Whether the mother chooses to breastfeed her baby or she feeds a substitute for human milk, you should respect her decision. But she cannot make this choice if she has not been well informed by you about the benefits of early and exclusive breastfeeding. Explain to her that it:
In some countries, there are beliefs about feeding newborn babies that are dangerous to the baby’s health. For example, in some places the baby is given food or liquids, such as water with sugar, honey, herbs, spices and animal milks, during the first 3 days after the birth before the woman begins breastfeeding. The thin, watery fluid called colostrum that her breasts produce during these 3 days may be thrown away because it is considered unclean.
What are the benefits of feeding colostrum to newborns? (You learned about this in Study Session 7 of this Module.)
Colostrum is rich in proteins and antibodies (special proteins produced by the mother’s immune system that help to protect her and the baby from infection).
Even after the woman’s breastmilk begins to flow, some people go on feeding other liquids and honey to the baby, in addition to breastfeeding.
What do you think are the reasons for this and what are the risks in doing so?
Breastfed babies may demand feeding frequently, so the mother may think that her breastmilk is not enough on its own. Feeding other liquids and honey to the baby is not necessary for nutrition and it increases the risk of infection from the spoon or feeding bottle.
For mothers who are HIV-negative:
You will learn how to advise mothers who are HIV-positive in Study Session 16 of this Module, on prevention of mother to child transmission (PMTCT).
During the antenatal period, discussions should begin concerning postpartum contraception options. Family planning information and services are important components of good quality antenatal care. These occasions provide an opportunity for health providers to discuss with women the benefits of birth spacing (leaving at least 2 years between births) for their health and the health of their current and future children. Help pregnant women and new mothers decide how they will avoid pregnancy after childbirth.
The return of fertility after birth is not entirely predictable, and conception can occur before the woman resumes her first menstrual period. A woman who is not fully and exclusively breastfeeding is able to become pregnant again as soon as 4 to 6 weeks after childbirth, and she should plan to begin some sort of contraception before starting to have sexual intercourse again. Full and exclusive breastfeeding gives good protection against conception, but cannot be relied on as 100% effective. A breastfeeding woman is usually protected from pregnancy only if:
Numerous safe methods of contraception are available for the breastfeeding woman.
For maximum protection, women after childbirth should not wait until the return of monthly bleeding to start a contraceptive method, but start as soon as safe guidance for her chosen method allows. (Some basic principles of contraception after miscarriage or induced abortion are given in Study Session 20 of this Module. Detailed discussion of all contraceptive methods and guidelines are given in the Family Planning Module in this curriculum.)
Intervals of at least 2 years have health benefits for both the woman and baby (Box 14.1).
Coordinate your family planning visits with an infant’s immunization schedule. And remember that optimal breastfeeding offers triple value: important improvements in child survival and health, better health for mothers, and temporary contraception.
In the next study session, you will learn about the principles of effective counselling, so you can communicate the health promotion messages to pregnant women sensitively during antenatal care, and address their concerns and beliefs about pregnancy and childbirth.
In Study Session 14 you learned that:
Now that you have completed this study session, you can assess how well you have achieved its Learning Outcomes by answering the following questions. Write your answers in your Study Diary and discuss them with your Tutor at the next Study Support Meeting. You can check your answers with the Notes on the Self-Assessment Questions at the end of this Module.
Suggest some ways to help women who cannot afford to buy a lot of different foods how they can get enough calories and a variety of foods.
Beans, peas and lentils are cheap and nourishing and quite easy to grow. Organ meats like liver, heart and kidney have a lot of iron and may cost less than other meats. Brown bread or brown rice and dark teff are more nutritious than the light-coloured grains and are usually cheaper to buy if she cannot grow her own.
Complete Table 14.1. Some of the categories have been left blank for you to write your answers.
|Food group||Contains||Three examples|
|Vitamins and minerals|
The table below is the completed version of Table 14.1. We do not know exactly which three examples you chose for each food group, so you may have mentioned other good examples.
|Food group||Contains||Three examples|
|Main foods||Carbohydrates||Injera, rice, maize, etc.|
|Grow foods||Proteins||Beans, eggs, meat, etc.|
|Go foods||Sugars and fats||Fruits, honey, nuts, etc.|
|Glow foods||Vitamins and minerals||Fish, dark green leafy vegetables, meat, etc.|
What advice should you give a pregnant woman on how to avoid infection in herself or her newborn baby? Think of at least three different actions she can take.
Some actions that you can advise a pregnant woman to take to avoid infection in herself and her newborn baby:
Which of the following statements is false? In each case, explain what is incorrect.
A Breastfeeding is 100% effective at preventing a further pregnancy.
B Colostrum should be fed to the newborn baby, not thrown away.
C Early and exclusive breastfeeding means feeding only breastmilk from the first hour of the baby’s life until at least 6 months of age.
D Even if menstrual periods return during exclusive breastfeeding, a woman does not need to begin another form of contraception.
E The benefits of birth spacing of at least 2 years include reduced risk of maternal and fetal death.
A is false. Breastfeeding is not 100% effective at preventing a further pregnancy; full and exclusive breastfeeding gives good protection from pregnancy but cannot be relied on as 100% effective —especially not after 6 months from the birth or if menstrual periods return.
B is true. Colostrum should always be fed to the baby because it is very nutritious and gives protection against infection.
C is true. Early and exclusive breastfeeding means feeding only breast milk from the first hour of the baby’s life until at least 6 months of age.
D is false. A woman who is breastfeeding exclusively does need to begin another form of contraception if her menstrual period returns.
E is true. Birth spacing of at least 2 years reduces the risk of maternal and fetal death.